Gramercy Court
Inspection history, citations, penalties and survey trends for this long-term care facility in Sacramento, California.
- Location
- 2200 Gramercy Drive, Sacramento, California 95825
- CMS Provider Number
- 555459
- Inspections on file
- 42
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Gramercy Court during CMS and state inspections, most recent first.
A resident with schizoaffective disorder and a history of assaultive behavior, care planned as at risk for physical aggression, suddenly stood up in the dining room and threw a heavy metal-framed chair at another resident with schizophrenia who was waiting nearby for a smoke break. A mental health worker observing the area briefly turned away to monitor other residents, and during that moment the chair was thrown, with no reported verbal exchange immediately beforehand. The targeted resident blocked the chair with a hand, later found on radiology to have soft tissue swelling and a mild fracture of the ring finger, and was observed with a hard splint extending from the finger to the elbow. Facility policy stated that residents have the right to be free from physical abuse, and leadership acknowledged that residents should be free from abuse.
The facility failed to protect several residents from physical abuse by other residents, contrary to its abuse-prevention policy. In separate incidents, a resident was slapped on the back of the head, another was punched in the face while in bed, a third was struck in the face resulting in a cut lip, and another was pushed to the floor after a verbal altercation, causing back and leg pain. These events involved residents with schizophrenia and varying levels of cognitive impairment and functional dependence, and were witnessed or confirmed by CNAs and the involved residents. The DON stated that all residents were expected to be free from abuse and safe, but multiple resident-to-resident assaults still occurred.
A resident with schizoaffective disorder and cognitive decline repeatedly abused other residents with serious mental health conditions. In one incident, the resident spat on another resident who was speaking loudly in the hallway. On a separate occasion in the dining room, the same resident stood up from a wheelchair, approached another resident seated at a table, and slapped him on the back of the head, an event witnessed by a social services assistant. In a third incident near the nurse’s station, the resident sat next to another resident attending a group and suddenly slapped her in the face, which was observed by an LPN. The DON later confirmed these witnessed events as physical abuse, in violation of the facility’s abuse prevention policy.
A resident with dementia and a history of falls was pushed by another resident with moderate cognitive impairment, resulting in a hip fracture. The incident was witnessed by an LPN and confirmed by the DON, with the aggressor admitting to the action. Facility policy requires protection from abuse by anyone, including other residents.
A resident with significant mental health disorders was physically assaulted by another resident, resulting in injuries such as a bleeding lip and scratches. Both individuals were documented as incapable of understanding their rights. The aggressor was previously observed exhibiting delusional and aggressive behavior, and later admitted to repeatedly hitting the other resident. The incident was confirmed by the DON, and facility policy requires protection from abuse by anyone, including other residents.
A resident with moderate cognitive impairment and a mental health condition was physically abused by another resident during a smoke break, when one resident slapped the other in response to an accidental wheelchair incident. Staff were present and witnessed the event, but failed to prevent the altercation, resulting in the affected resident experiencing pain and feelings of unsafety.
A resident with cognitive impairment physically assaulted another cognitively intact resident after an altercation involving a mental health worker. The incident resulted in the assaulted resident sustaining a head injury and a skin tear, requiring medical evaluation. Facility records and staff interviews confirmed the event, and the DON acknowledged the expectation that all residents be protected from physical abuse.
A resident with bipolar schizoaffective disorder and good cognitive status eloped from the facility after accessing a basketball patio area where exit doors were unlocked, lacked functioning alarms, and had non-working security keypads. Staff confirmed the area was under renovation and should not have been used by residents, but the unsecured exits allowed the resident to leave undetected.
The facility failed to properly store and label medications, with personal belongings found in a medication room, expired and unidentifiable medications in carts, and a resident's ointment left at the bedside without proper authorization. Additionally, a treatment cart was left unlocked, violating facility policies.
A resident with a left hip fracture and moderate memory impairment was observed with her back and side exposed while sitting in a wheelchair, failing to maintain her dignity. Staff confirmed the exposure and acknowledged the need for additional coverage, as per the facility's dignity policy.
A resident was prescribed three psychotherapeutic drugs without obtaining informed consent, as required by the facility's policy. Despite the resident's intact cognition and diagnosis of anxiety, the facility failed to document consent for buspirone, duloxetine, and lorazepam. Interviews with staff confirmed the oversight, highlighting a lapse in following the policy that mandates consent every six months and upon changes in medication or risk.
A resident was found with medications accessible at her bedside without a completed self-medication administration assessment. The resident, admitted with anxiety and having intact memory, had anti-fungal, anti-itching, and antibiotic creams given by staff for bedside use. The ADON confirmed these should have been locked, and the DON noted the absence of a required assessment, which is against facility policy.
A facility failed to complete a discharge MDS assessment for a resident within the required 14-day timeframe after the resident was discharged to the hospital. The oversight was confirmed by the MDS Coordinator and DON, who acknowledged that the assessment should have been completed and submitted promptly according to the RAI manual.
A facility failed to develop a hospice care plan for a resident admitted with multiple diagnoses, including frequent falls, malnutrition, and palliative care needs. During interviews and record reviews, both an LN and the DON confirmed the absence of a hospice care plan, which was against the facility's policy requiring coordination with the hospice plan of care.
The facility failed to adhere to physician orders and professional standards for three residents. A resident's hospice care order was not transcribed to the OSR, another resident's heparin sodium order was incorrectly recorded as an intramuscular injection, and a third resident was given metformin without food, contrary to the physician's order. These deficiencies were confirmed by the DON and licensed nurses, highlighting a lack of adherence to facility policies.
The facility failed to properly monitor and manage psychotropic medications for two residents. One resident did not receive an annual gradual dose reduction for medications used for anxiety, while another was given lorazepam PRN for more than 14 days without a stop date or rationale. These actions were against the facility's policies.
The facility failed to provide weekly and alternate menus to three residents, impacting their ability to choose meals according to their preferences. Residents expressed dissatisfaction with the lack of menu options, and staff interviews revealed a breakdown in the menu distribution process. The Dietary Supervisor prepared menus, but they were not distributed to residents as required by facility policy.
A resident with type 2 diabetes mellitus was not provided with the necessary adaptive eating equipment as ordered by an occupational therapist. The resident's meals were served on a single plate instead of in bowls, as required, leading to difficulty in eating. This was confirmed by both a licensed nurse and the DON, highlighting a failure to adhere to the facility's policy on meal assistance.
During a survey, expired and undated food items were found in the facility's kitchen, including spices, dried beans, lactose-free drinks, bread, cheese, and turkey. The Dietary Supervisor confirmed these items were improperly stored, and the Director of Nursing emphasized the importance of maintaining sanitary conditions to prevent food-borne illnesses.
A resident with chronic pain conditions did not receive timely pain medication upon admission, leading to prolonged periods of severe pain. The facility failed to reassess the resident's pain within the required timeframe after medication administration and inconsistently offered non-drug interventions. Interviews with the DON and nursing staff confirmed these deficiencies, highlighting a lack of adherence to the facility's pain management policy.
The facility did not report the results of an investigation into a resident-to-resident altercation to the State Survey Agency within the required 5 working days. The incident involved two residents, one with schizophrenia and the other with Alzheimer's disease. The Director of Nursing acknowledged the failure to comply with the facility's policy, which mandates reporting alleged abuse violations and investigation results within the specified timeframe.
A resident's right to respect and dignity was compromised when the facility failed to maintain an accurate inventory of personal property, resulting in the loss of the resident's mobile phone. The resident was admitted with the phone, confirmed by staff and the resident's wife, but it was missing upon discharge. The inventory was incomplete, undated, and unsigned, not adhering to facility policy.
A resident required CPR, but two CNAs provided it without current certification, contrary to facility policy. The resident, with a full code status, was found unresponsive, and CPR was initiated by CNAs who did not call 911. The facility's policy mandates CPR by certified staff or calling 911 if the responder is uncertified. Interviews confirmed the CNAs' lack of certification and inadequate training, highlighting a deficiency in CPR policy implementation.
A resident with a history of elopement and under conservatorship eloped during a group outdoor walking activity due to inadequate supervision. Despite being identified as at risk for elopement, the resident was not properly monitored by the four staff members supervising the activity. The staff failed to notice the resident's departure, and the facility's protocols for supervision were not effectively followed.
A resident with schizophrenia was struck by another resident with schizoaffective disorder, resulting in injuries requiring hospitalization. The incident occurred because CNAs present did not attempt verbal de-escalation, contrary to facility policy. The facility's policy mandates staff training in managing aggressive behavior to prevent abuse.
A facility failed to provide safe pharmaceutical services when a nurse left a resident's brimonidine eye drops unsupervised in the room. The resident, with moderately impaired cognition and multiple diagnoses, had their eye drops misplaced and later found on a food tray. Facility policy requires staff to be present during medication administration and to keep medications locked when not in use.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Finger Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when another resident threw a chair that caused injury. One resident with schizoaffective disorder, a history of assaultive behavior, poor impulse control, fixated delusional thoughts, and agitation was care planned as being at risk of becoming physically aggressive toward others, with interventions to assess and anticipate needs and intervene before agitation escalates. Another resident with schizophrenia and a history of assaultive behavior was care planned as being at risk for behavioral disturbances, with an intervention to provide a secure and comfortable environment. Both residents were documented as alert, oriented, and able to make their needs known. On the day of the incident, the two residents were in the small dining room waiting for a smoke break. According to nursing notes and staff interviews, the resident with schizoaffective disorder suddenly stood up, lifted the chair she had been sitting on, and threw it toward the other resident, stating she believed the other resident was going to hurt her brother. A mental health worker, positioned at the entry to the dining room to observe residents inside the room and in the hallway, briefly turned away to watch residents passing through the hallway and nurses’ station area. When the worker looked back, the resident had already stood up, grabbed the chair, and thrown it; the worker reported the event happened too quickly to intervene and did not recall any verbal interaction between the two residents immediately beforehand. The resident who was struck reported that she blocked the incoming chair with her hand, describing the chair as heavy with a metal frame and padded seat, back, and armrests. She stated that her ring finger was broken, that it did not hurt at the time of the interview, and that she believed the act was intentional, possibly related to something said previously. Radiology results documented soft tissue swelling and a mild fracture. At the time of surveyor observation, the injured resident had a hard splint from the ring finger to the left elbow wrapped with gauze. Facility policy on abuse, neglect, exploitation, and misappropriation prevention stated that residents have the right to be free from abuse, including physical abuse, and the ADON affirmed that residents should be free from abuse.
Failure to Protect Residents From Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents, despite a policy stating residents have the right to be free from abuse and neglect and must be protected from abuse by anyone, including other residents. One resident with schizophrenia, major depression, anxiety disorder, and moderate cognitive impairment (BIMS 10/15) was slapped on the back of the head by another resident with schizophrenia, memory loss, and severe cognitive impairment (BIMS 3/15), as witnessed by a CNA; the victim later reported feeling upset. In another incident, a resident with schizophrenia and intact cognition (BIMS 13/15) was documented as striking his roommate, a resident with schizophrenia, need for assistance with personal care, and moderately impaired cognition (BIMS 12/15), while appearing highly psychotic, unable to follow directions, and aggressive toward staff. The roommate later stated he was punched in the face while in bed and felt scared, and a CNA reported seeing punches thrown. Additional incidents included a resident with schizophrenia and need for assistance with personal care, with intact cognition (BIMS 13/15), entering the room of the same moderately cognitively impaired resident, who then struck him in the face, causing a mild tear and slight bleeding of the lip; the aggressor later confirmed hitting the other resident on the lip. In a separate event, a resident with schizophrenia, restlessness, agitation, and severe cognitive impairment (BIMS 6/15) engaged in a verbal altercation with another resident with schizophrenia, difficulty walking, memory problems, chronic pain syndrome, and moderate cognitive impairment (BIMS 10/15), which escalated to the first resident pushing the second. The pushed resident reported being shoved on the shoulders, falling to the ground, and experiencing back and leg pain, and a CNA confirmed witnessing the intentional push that caused the fall. The DON stated her expectation that all residents be free from abuse and safe in the facility, but the documented resident-to-resident assaults demonstrate that residents were not protected from physical abuse as required by facility policy.
Failure to Prevent Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by another resident on three separate occasions. Resident 1, who had schizoaffective disorder and age-related cognitive decline, was admitted in December 2025. On 12/13/25 at approximately 4 p.m., Resident 1 was standing in the hallway using a walker when Resident 2, who had schizoaffective disorder and depression, was positioned in front of him and speaking loudly to himself. Resident 1 became upset by Resident 2’s behavior and spat on Resident 2. Resident 2 later confirmed that another resident had spit on him about a month prior and expressed more concern about staff than other residents when asked if he felt safe. On 12/24/25, Resident 1 physically abused Resident 3 in the dining room. Resident 3, who had schizophrenia and dementia and had been admitted in April 2024, was seated at a table drinking coffee. Resident 1 was observed standing from his wheelchair, approaching the table where Resident 3 was seated, and then slapping Resident 3 on the back of the head, producing an audible sound. A social services assistant witnessed the incident and reported that Resident 3 looked shocked and confused, and that Resident 1 stated he slapped Resident 3 because Resident 3 was looking at him in a “weird way.” Resident 3 later stated he had been hit on the back of the head by “some guy,” though he did not recall exactly when. On 12/26/25, Resident 1 physically abused Resident 4 near the nurse’s station. Resident 4, who had schizoaffective disorder and PTSD and had been re-admitted in March 2024, was sitting near the nurse’s station attending a group when Resident 1 walked toward her, sat down next to her, and suddenly struck the right side of her face with his hand. A licensed nurse witnessed the event, described hearing an audible slap, and reported that Resident 4 cried and said that Resident 1 had slapped her. During a later interview, Resident 4, who demonstrated confusion and difficulty providing appropriate responses, expressed fear about a fire and recounted being slapped by a man, stating it was her word against everybody else. The DON confirmed that the three witnessed incidents between Resident 1 and Residents 2, 3, and 4 constituted physical abuse, contrary to the facility’s abuse prevention policy, which states residents have the right to be free from physical abuse and other forms of mistreatment.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident 1, who had diagnoses including anxiety disorder, dementia, a history of falls, and a mental health condition with hallucinations and mood swings, was observed walking in the hallway. Resident 2, who had anxiety disorder, intellectual disabilities, and a similar mental health condition, was seated nearby and suddenly stood up and pushed Resident 1 without warning. This action caused Resident 1 to fall onto her left side, resulting in limited mobility in her left leg and hip. An x-ray confirmed an intertrochanteric fracture with varus deformity near the hip, and Resident 1 was subsequently transferred to the hospital for further care. Interviews confirmed that Resident 2 admitted to pushing Resident 1 because she was tired of hearing her voice. A licensed nurse witnessed the incident, stating that Resident 2 stood up and pushed Resident 1 with both hands, causing the fall and injury. The Director of Nursing confirmed the incident and acknowledged that all residents have the right to be free from abuse. Review of the facility's policy indicated that residents must be protected from abuse by anyone, including other residents.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. One resident, who had a history of mental health disorders including hallucinations, delusions, anxiety, impulse disorder, and mood disorder, was found with injuries including a bleeding lip, scratches on the forearm, and redness to the hand knuckles after being punched in the face by another resident. Both residents involved were documented as incapable of understanding their rights, responsibilities, and informed consent. Prior to the physical altercation, the aggressor was observed yelling profanities and exhibiting racially preoccupied, delusional behavior toward the victim. Progress notes and interviews confirmed that the aggressor admitted to repeatedly hitting the other resident until he fell to the floor. The incident was acknowledged by the DON, who confirmed that all residents have the right to be free from abuse. The facility's policy also states that residents must be protected from abuse by anyone, including other residents. The failure to prevent this altercation resulted in physical harm to the resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a mental health condition was physically abused by another resident. The incident took place during a smoke break, when the first resident, while maneuvering his wheelchair, accidentally rolled over the other resident's foot. In response, the second resident slapped the first resident on the left cheek, causing immediate pain rated as 8 out of 10. The event was witnessed by a mental health worker, who reported hearing a loud slapping sound and observed the affected resident holding his face in pain. The incident was also confirmed by the Director of Nursing, who acknowledged that staff were present at the time but failed to prevent the altercation. The affected resident reported feeling unsafe and disrespected as a result of the incident. Facility records and interviews confirmed that the altercation was witnessed by staff, and that the facility's policies require protection of residents from abuse, including abuse by other residents. Despite these policies and staff presence, the facility failed to prevent the physical abuse, resulting in both physical and emotional harm to the resident.
Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder and bipolar type, who was cognitively intact, was physically assaulted by another resident with schizophrenia and severely impaired cognition. The incident took place when the cognitively intact resident attempted to intervene during an altercation between the second resident and a mental health worker. The second resident, after being told to wait his turn during an exercise group, became agitated, held the mental health worker down, and spat on her. The first resident intervened to assist the staff member, at which point the second resident pushed the first resident against a wall, causing the resident's head to hit the wall and resulting in a skin tear on the right elbow, a bump to the head, and subsequent complaints of headache, nausea, and dizziness. Facility records and staff interviews confirmed that the altercation was witnessed and documented, and that the resident who was assaulted required transfer to a medical center for further evaluation. The facility's policy states that all residents have the right to be free from abuse, including abuse by other residents. The Director of Nursing acknowledged that residents should be protected from physical abuse within the facility. The failure to prevent this incident resulted in the resident not being free from abuse as required by facility policy.
Resident Elopement Due to Unsecured Exit During Patio Renovation
Penalty
Summary
The facility failed to maintain a safe environment for one resident who eloped from the premises through an unsecured exit gate. The resident, admitted with a diagnosis of bipolar schizoaffective disorder and assessed as having good memory and judgment, was outside on the basketball court patio with other residents when staff noticed the resident was missing. A search was conducted, but the resident was not found on the premises. Observations revealed that the basketball patio area had two exit doors with non-functioning security keypads, no working alarm speaker boxes, and both doors were unlocked and easily opened, leading directly to the parking lot. Staff confirmed that the area was under renovation and should not have been accessible to residents, and that the exit gates were not secured or alarmed as required. Facility policies reviewed indicated that all doors and locking mechanisms should always be working to prevent such incidents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, which was observed during a survey. Personal belongings were found in the Hall C medication room, which were confirmed to belong to a licensed nurse. Expired medications were discovered in two medication carts, with one cart containing 31 expired pills of carvedilol and another cart containing unidentifiable medications with unreadable labels. Additionally, two multi-dose liquid protein bottles without open dates and an expired inhaler were found in a medication cart. The liquid protein bottles were opened and partially used without being marked with open dates as required by the manufacturer's instructions. Furthermore, a tube of menthol ointment was found on a resident's bedside table without a physician's order for self-administration or bedside storage. The Director of Nursing confirmed that personal belongings should not be stored in medication rooms, and expired or discontinued medications should be removed from carts. Additionally, a treatment cart was left unlocked and unattended for 10 minutes while a treatment nurse was providing wound care, which could allow unauthorized access to medications. The facility's policies require medications to be stored in locked compartments and for medications brought by residents to be kept in the med cart unless approved for bedside storage by a physician.
Failure to Maintain Resident Dignity Due to Inadequate Clothing Coverage
Penalty
Summary
The facility failed to promote dignity for a resident, identified as Resident 27, who was observed wearing a gown with her back and side of her body exposed while sitting in a wheelchair. This incident was noted during an observation where Resident 27 wheeled herself into the hallway, and staff did not cover her exposed back. The resident had been admitted to the facility with a diagnosis of a left hip fracture and required substantial to maximal assistance with dressing due to moderate memory impairment. Further observations revealed that Resident 27's back and side were exposed while she was sitting in her wheelchair near the entrance of her room, with staff and other residents passing by. Certified Nursing Assistants (CNAs) confirmed the exposure and acknowledged that it should have been covered with another gown or shirt. The Director of Nursing also stated that Resident 27 would feel embarrassed by the exposure and expected staff to provide a second gown for coverage. The facility's policy on dignity emphasized caring for residents in a manner that promotes their well-being and self-esteem.
Failure to Obtain Informed Consent for Psychotherapeutic Drugs
Penalty
Summary
The facility failed to obtain informed consent for the use of psychotherapeutic drugs for a resident, identified as Resident 43, who was prescribed three such medications without proper consent. Resident 43 was admitted to the facility with a diagnosis of anxiety and had intact cognition as per the Minimum Data Set assessment. The resident was prescribed buspirone, duloxetine, and lorazepam, but there was no documentation of informed consent for these medications in the resident's medical record. During interviews with the Medical Record staff, Assistant Director of Nursing, and Director of Nursing, it was confirmed that informed consent was not obtained for the psychotherapeutic drugs prescribed to Resident 43. The facility's policy requires informed consent to be obtained every six months for such medications, and further consent is needed if there are changes in medication or risk. However, the facility did not adhere to this policy, as evidenced by the lack of informed consent documentation for the prescribed medications.
Failure to Complete Self-Medication Assessment for Resident
Penalty
Summary
The facility failed to complete a self-medication administration assessment for a resident, identified as Resident 43, who had medications accessible and stored on top of a bedside table. Resident 43 was admitted to the facility in January 2020 with a diagnosis of anxiety and had a perfect score on a mental status assessment, indicating intact memory. During an observation and interview, it was noted that Resident 43 had a plastic container with multiple anti-fungal, anti-itching, and antibiotic creams at her bedside, which she stated were given to her by the nurse and certified nursing assistant for her to keep at bedside when needed. The Assistant Director of Nursing confirmed the presence of these medications at the resident's bedside and acknowledged that they should have been kept locked in the medication cart. Further review of Resident 43's medical record revealed no Self-Medication Administration Assessment had been completed. The Director of Nursing also confirmed the absence of this assessment and stated that medications should not be left at the bedside as other residents could potentially access them. The facility's policy on self-administration of medications requires an interdisciplinary team to determine if it is clinically appropriate and safe for a resident to self-administer medications.
Failure to Complete Discharge MDS Assessment on Time
Penalty
Summary
The facility failed to complete a discharge Minimum Data Set (MDS) assessment for a resident within the required timeframe. The resident was admitted to the facility and discharged to the hospital 13 days later. However, the discharge assessment was not completed and submitted within 14 calendar days as mandated by the Resident Assessment Instrument (RAI) manual. This oversight was confirmed during interviews and record reviews with the Business Office Consultant, MDS Coordinator, and Director of Nursing. The MDS Coordinator acknowledged that the discharge assessment should have been completed and submitted within the specified timeframe. The Director of Nursing also confirmed that the assessment should have been completed immediately after the resident's transfer to the hospital. The facility's policy on MDS completion and submission timeframes, which aligns with the RAI manual, was not adhered to in this instance, leading to the deficiency.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop a hospice care plan for Resident 254, who was admitted in November 2024 with multiple diagnoses, including frequent falls, malnutrition, and palliative care needs. During interviews and record reviews conducted on December 5, 2024, both a Licensed Nurse (LN 1) and the Director of Nursing (DON) confirmed that no hospice care plan had been developed for Resident 254. This oversight was contrary to the facility's policy, which requires obtaining the most recent hospice plan of care specific to each resident and coordinating it with the care and services provided by the facility.
Failure to Adhere to Physician Orders and Professional Standards
Penalty
Summary
The facility failed to provide services according to professional standards of quality for three residents. Resident 254's physician order to admit to hospice care was not transcribed to the order summary record (OSR), despite being noted in the progress notes. This oversight was confirmed by both a licensed nurse and the Director of Nursing (DON) during a review of the resident's records. The facility's policy on hospice care requires coordination with the care and services provided, which was not adhered to in this instance. Resident 255's physician's order for heparin sodium was incorrectly recorded in the OSR as an intramuscular injection instead of subcutaneous, which could cause muscular tissue damage. This error was identified and confirmed by both a licensed nurse and the DON. Additionally, Resident 257 was not given metformin hydrochloride as prescribed by the physician, which required administration with meals. The licensed nurse administered the medication without food, contrary to the physician's order, which was confirmed by the DON. The facility's policy on administering medications requires adherence to prescriber orders, which was not followed in this case.
Failure to Monitor and Manage Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper monitoring and management of psychotropic medications for two residents. Resident 43, who was admitted with a diagnosis of anxiety, did not receive an annual gradual dose reduction (GDR) for psychotropic medications, including buspirone, duloxetine, and lorazepam, despite being on these medications for over a year. The Assistant Director of Nursing confirmed that no GDR was attempted in 2023, which was against the facility's policy requiring annual GDR attempts after the first year of medication use. Resident 30, diagnosed with dementia and agitation, was administered lorazepam on a PRN basis for more than 14 days without a stop date or a documented rationale for continued use. The Director of Nursing and Assistant Director of Nursing confirmed that the doctor's order lacked a rationale for extending the PRN order beyond 14 days, which violated the facility's policy limiting PRN psychotropic medication orders to 14 days unless a specific condition necessitated its use.
Failure to Provide Menus to Residents
Penalty
Summary
The facility failed to provide weekly and alternate menus to three residents, which decreased the potential to meet their nutritional and cultural preferences. Resident 204, admitted with a disorder of electrolyte and fluid imbalance, expressed dissatisfaction with the lack of menu options and the inability to choose her food preferences. Similarly, Resident 24, with type 2 diabetes mellitus, reported that he did not like the meals served and was unaware of upcoming meals due to the absence of a menu. Resident 38, diagnosed with morbid obesity and type 2 diabetes mellitus, also expressed uncertainty about meal options and resorted to eating instant noodles when dissatisfied with the facility's food. Interviews with facility staff revealed a breakdown in the distribution process of menus. The Dietary Supervisor stated that menus were prepared weekly with the dietician and left at nurse stations for distribution. However, Licensed Nurse 9 confirmed that nurses were not responsible for distributing menus to residents. The Director of Nursing indicated that the activities department should have distributed the menus, and the dietician should have ensured residents received them. The facility's policy required the activities department to distribute menus and the dietician to confirm their distribution, but this was not followed, leading to the deficiency.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide necessary adaptive equipment for a resident, identified as Resident 46, who required special eating equipment as per their care plan. Resident 46, who was admitted in July 2020 with a diagnosis of type 2 diabetes mellitus, had an order from an occupational therapist to have meals served in bowls to assist with eating. However, during an observation, it was noted that the resident's lunch was served on a single plate, contrary to the order. The resident was observed transferring food to a cup, indicating difficulty with the provided setup. Licensed Nurse 8 confirmed that the resident's meal was not served according to the order, which was also verified by the Director of Nursing. The facility's policy on meal assistance, revised in March 2022, states that adaptive devices should be provided for residents who need them, and assistance should be given to ensure residents can use and benefit from special eating equipment. This oversight decreased the facility's potential to meet the resident's nutritional needs.
Improper Food Storage and Expired Products Found in Facility
Penalty
Summary
The facility failed to properly store food in accordance with professional standards for food safety, as observed during a survey. During an initial kitchen tour, the Dietary Supervisor (DS) identified several expired food items, including two spice bottles, a box of dried beans, and a 12-pack box of lactose-free drinks, all past their use-by dates. Additionally, undated food products, such as loaves of bread, a block of cheese, and a container of cooked sliced turkey, were found in the dry storage area and walk-in refrigerator. The DS confirmed these items were either expired or lacked proper dating, which is necessary to ensure food safety. The Director of Nursing (DON) stated that kitchen staff are expected to regularly check and clean storage areas, including refrigerators, to maintain sanitary conditions. The facility's policy on Food Receiving and Storage, revised recently, requires that foods be received and stored in compliance with safe food handling practices. The failure to adhere to these standards increased the potential for food-borne illnesses among the residents, as expired and improperly stored food can pose health risks.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 1, who was admitted with multiple diagnoses including cellulitis, chronic pain syndrome, osteoarthritis, and osteonecrosis. Upon admission, the resident was not administered prescribed pain medication for eight hours, despite experiencing severe pain. The facility's records indicated that the resident's pain was not assessed in a timely manner, and non-pharmacological interventions were not consistently offered as per the care plan. The facility's documentation revealed multiple instances where the resident's pain was not reassessed within the expected timeframe after administering pain medication. For example, on several occasions, the reassessment of pain occurred two to three hours after medication administration, contrary to the facility's policy which required reassessment within one hour. Additionally, there were inconsistencies in offering non-drug interventions, and the resident was not always medicated according to the physician's orders, as evidenced by an instance where only one tablet of oxycodone was administered instead of two for severe pain. Interviews with the Director of Nursing (DON) and licensed nurses confirmed these deficiencies. The DON acknowledged the failure to administer pain medication timely and the lack of consistent reassessment of pain. The nursing staff also confirmed that pain reassessment should occur within 30 to 45 minutes post-medication, and if pain relief was ineffective, further interventions should be pursued. The facility's 'Pain Assessment and Management' policy emphasized the importance of timely pain assessment and intervention, which was not adhered to in this case.
Failure to Report Resident Altercation Investigation
Penalty
Summary
The facility failed to complete and report the results of an investigation of a resident-to-resident altercation to the State Survey Agency within the required 5 working days. This incident involved two residents, one with schizophrenia and major depressive disorder, and the other with Alzheimer's disease and moderate cognitive impairment. The altercation occurred on November 7, 2024, but the results of the investigation were not reported as mandated by the facility's policy. During an interview, the Director of Nursing confirmed the failure to report the investigation results within the stipulated timeframe. The facility's policy, revised in October 2022, clearly states that all alleged violations of abuse and the results of investigations must be reported to the State Agency within 5 working days. This oversight had the potential to subject residents to further incidents of abuse.
Failure to Maintain Accurate Inventory of Resident's Personal Property
Penalty
Summary
The facility failed to ensure respect and dignity for a resident by not maintaining an accurate inventory of the resident's personal property. The resident was admitted with a mobile phone, which was confirmed by the resident's wife, a licensed nurse, and a certified nursing assistant. However, upon discharge, the resident's mobile phone was missing, and there was no signed or provided inventory of personal items at admission or discharge. The inventory of personal effects only listed a watch and a polo shirt, lacked signatures, and was undated, indicating non-compliance with the facility's policy and procedure. Interviews with the Social Services Director, Director of Staff Development, and Director of Nursing revealed that the inventory process was not properly conducted. The facility's policy required a detailed inventory of personal effects to be completed and signed by staff and family members, with a copy provided to the resident or family. The Director of Nursing confirmed that the inventory did not follow the facility's policy, and the resident's mobile phone should have been included. This oversight resulted in the unrecovered loss of the resident's mobile phone.
Deficiency in CPR Policy Implementation
Penalty
Summary
The facility failed to implement its cardiopulmonary resuscitation (CPR) policy for a resident who required emergency resuscitation. Two certified nursing assistants (CNAs) provided CPR to the resident without maintaining current CPR certification. The resident, who had a history of schizoaffective disorder, drug abuse, and diabetes, was found unresponsive with seizure-like activity. Despite the resident's full code status, the CNAs initiated CPR without current certification, and one of them did not call 911. The facility's policy requires that CPR be initiated by a licensed staff member certified in CPR/BLS, or if the first responder is not certified, they should call 911 and follow instructions until certified staff arrive. Interviews revealed that CNA 1 and CNA 2 both assisted in providing CPR without current certification, and neither called 911. CNA 1's CPR card was expired, and CNA 2's CPR certification was not provided. The Director of Staff Development confirmed that during the latest CPR training, only nurses were checked for hands-on CPR skills, not CNAs. The facility's administrator acknowledged that staff providing CPR should have current certification. This deficiency decreased the facility's potential to provide high-quality CPR during emergencies.
Resident Elopement During Outdoor Activity Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate monitoring and supervision for a resident who eloped during a group outdoor walking activity. The resident, who was under conservatorship and had a history of elopement attempts, was admitted with diagnoses including bipolar type schizoaffective disorder and diabetes. Despite being able to walk independently, the resident was identified as at risk for elopement in their care plan. During the walking activity, the resident was part of a group of 19 residents supervised by four staff members. However, the staff did not notice when the resident left the group, and the resident was discovered missing upon the group's return. Interviews with the walking activity staff revealed that although the resident's participation was noted on the sign-in sheet, the staff did not see the resident leave the group. The staff confirmed that they did not conduct a head count during the activity, which contributed to the oversight. The facility's policy and procedure documents emphasized the importance of maintaining a safe environment and supervising residents during group activities, but these protocols were not effectively implemented, leading to the resident's unsupervised departure.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when he was struck in the face by another resident, resulting in a swollen eye, severe headache, and vomiting that required hospitalization. Resident 1, who was admitted with schizophrenia, was attacked by Resident 2, who was admitted with schizoaffective disorder. The incident was documented in the progress notes by a Licensed Nurse, and Resident 2 admitted to striking Resident 1. Interviews with the Program Director and Director of Nursing revealed that the Certified Nursing Assistants present during the altercation did not attempt to verbally de-escalate the situation, which was against the facility's policy. The facility's policy on abuse prohibition and prevention, dated November 2017, requires staff to be trained in appropriate interventions to manage aggressive behavior and prevent abuse. The failure to intervene and de-escalate the situation led to the abuse incident.
Unsafe Pharmaceutical Practices
Penalty
Summary
The facility failed to provide safe pharmaceutical services for a resident when a Licensed Nurse left the resident's brimonidine eye drops unsupervised in the room. The resident, who had moderately impaired cognition and required assistance with personal care, was admitted with multiple diagnoses including primary open-angle glaucoma and insomnia. During a morning medication pass, the Licensed Nurse left the eye drops in the resident's room and stepped out. Upon returning, the nurse found the eye drops missing, which were later discovered on the resident's food tray by kitchen staff. The Certified Nursing Assistant confirmed that the resident was confused and needed redirection, often grabbing and moving items around. The Nursing Supervisor and Director of Nursing both confirmed that the facility's policy required staff to be present when administering medications and that medications should not be left in residents' rooms. The Director of Nursing emphasized that medications should be returned to the medication cart after administration. A review of the facility's policy on medication storage indicated that medication supplies should remain locked when not in use or attended by authorized personnel. The incident was documented in the resident's Progress Note, which indicated that only one eye drop bottle was found at the time, and the other medications were locked in the nurse's cart.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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