Height Street Skilled Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Bakersfield, California.
- Location
- 1611 Height Street, Bakersfield, California 93305
- CMS Provider Number
- 555902
- Inspections on file
- 46
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Height Street Skilled Care during CMS and state inspections, most recent first.
A resident with moderately impaired cognition experienced ongoing episodes of loose stools over multiple days, reaching the facility-defined threshold for a change of condition, but the physician was not notified until many days later despite policy requiring timely notification. When the physician was finally contacted, an order for loperamide 2 mg Q8H PRN was obtained; however, MAR review showed that no doses were administered even though documentation indicated the resident continued to have loose stools. The DON acknowledged that the medication should have been given and that there was a delay in treatment due to poor communication among nursing staff, and the resident ultimately requested transfer to the hospital for diarrhea and abdominal pain.
A resident with dementia, Alzheimer’s disease, depression, cognitive communication deficits, and a need for extensive assistance with eating and personal care was allegedly slapped on the face by a family member during a feeding interaction, resulting in facial discoloration. A CNA later reported that she witnessed the incident and stated she informed an LVN immediately, but that the LVN told her not to say anything. The LVN denied being told about the abuse and recalled only being told the resident was aggressive. The allegation was not reported to facility administration until several weeks after the incident, contrary to the facility’s abuse policy requiring prompt reporting of suspected abuse within specified timeframes.
Surveyors found that the facility did not ensure residents’ access to private telephone communication when an LTCO repeatedly could not reach residents because calls transferred from the receptionist to the nurses’ station went unanswered and to voicemail, which he could not use for confidential communication. A cognitively intact resident who relies on the facility phone reported that people told him they had called but their calls were not put through, and a family member reported that while she could reach her relative during daytime hours, she could not reach anyone by phone after the receptionist left. The facility’s own resident rights policy states that residents have the right to privacy and confidentiality in communications and to use a telephone in privacy.
A resident was admitted with documented personal items, including clothing and linens, listed on an Inventory List completed at admission. At the time of discharge, there was no documentation that these belongings were returned to the resident or a representative, and no signed receipt was obtained. The DON confirmed that the record lacked evidence that the resident’s property was provided at discharge, despite facility policy requiring completion of a resident inventory at admission and discharge, provision of the property and inventory copy to the resident or representative, and obtaining a signed receipt.
A resident was discharged without being provided a documented home medication list, contrary to the facility’s stated discharge process. An LVN reported that residents are supposed to receive their medications with a written list and instructions, and that staff educate the resident and obtain a signature to verify this education. Review of the resident’s Discharge Instruction Form showed medications were noted as provided and an attachment was referenced, but no medications were actually listed, and the DON confirmed there was no evidence the resident received a home medication list. The facility did not supply a related policy or procedure when requested by surveyors.
A resident with major depressive disorder and paraplegia did not receive required non-pharmacological interventions when expressing increased sadness, and was not monitored every shift for 72 hours after an increase in Lexapro dosage. Staff failed to follow the care plan and facility policy, resulting in the resident being found deceased with evidence of self-harm. Documentation and interviews confirmed that necessary interventions and monitoring were not provided or recorded.
Two residents experienced unsanitary conditions, including a foul-smelling bathroom and unclean shower rooms with stained tiles. Housekeeping staff confirmed difficulties in removing persistent odors and acknowledged buildup in shower areas, contrary to facility policy requiring clean and pleasant living spaces.
Two residents with high fall risk, identified by admission assessments and medical diagnoses such as muscle weakness, gait abnormalities, and Alzheimer's disease, did not have baseline care plans with fall prevention interventions developed within the required 48-hour timeframe. Instead, care plans were delayed by seven and 26 days, contrary to facility policy and confirmed by the DON.
A resident with Alzheimer's disease, muscle weakness, and high fall risk was found in a bed that was not kept in the low position as required by their care plan and facility policy. A family member and staff confirmed the bed was not lowered, despite the resident's risk and documented interventions.
A resident with dementia and a history of pain reported arm pain to two CNAs, who did not provide pain relief or notify the LN. The LN became aware of the pain only after being approached by surveyors, and the resident continued to experience pain for at least 40 minutes. Facility policy required immediate communication and intervention for reported pain, which was not followed.
Two residents with significant care needs experienced long delays in call light response, with one waiting hours for incontinence care and another waiting 45 minutes for water at night. Both were cognitively intact and reported their concerns, and the DON acknowledged that such delays were not acceptable according to facility policy.
Two residents did not receive care as outlined in their care plans: one was not repositioned every two hours despite a history of pressure injuries, and another was left unsupervised during meals despite requiring assistance and redirection. Staff confirmed these lapses, and documentation showed both residents were dependent on staff for their respective needs.
The facility did not ensure that nursing services provided met professional standards of quality, as identified by surveyor observation and review of facility practices.
Three residents reported excessive delays in call light response, with wait times ranging from five minutes to two hours. These residents, who were cognitively intact and required assistance for brief changes and repositioning due to conditions such as pressure injuries, described staff walking by without responding and expressed feelings of anxiety, anger, and frustration. Facility policy requires prompt response to call lights, but this was not consistently observed.
Two cognitively intact residents were disturbed when a CNA entered their room at 4 a.m. singing and chanting loudly, waking them from sleep. Despite prior complaints and instructions to stop, the CNA continued this behavior, which did not align with facility policy requiring staff to treat residents with dignity and respect.
A resident with mild protein-calorie malnutrition experienced notable weight loss, and the RD's recommendations to liberalize the diet and increase nutritional supplements were not communicated to the physician or implemented. Facility policy requiring physician notification and documentation of RD recommendations was not followed, as confirmed by DON and ADON.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
The facility did not report missing narcotic medications from the E-kit to CDPH as required by its own policy. The DON confirmed the discovery of missing oxycodone, Percocet, and Norco, and the Administrator acknowledged that the incident was not reported, despite clear policy requirements for timely notification of such occurrences.
A resident with multiple serious diagnoses was given Norco, a narcotic pain medication, outside the prescribed pain scale parameters, and staff failed to document reassessment of the medication's effectiveness as required by facility policy. The DON confirmed these lapses in both administration and documentation.
Surveyors found that medications, including ointments, tablets, inhalers, and controlled substances, were left on the bedside tables of several residents who were not authorized or assessed as capable of self-administering their medications. Nursing staff confirmed that these residents should not have had access to their medications at bedside, and facility policy prohibits this practice. The deficiency was identified through direct observation, record review, and staff interviews.
Milk was served to a resident at a temperature of 46°F, exceeding the facility's policy requirement of less than 41°F. This was confirmed by the Dietary Manager during a test tray delivery, and facility policies specify that milk should be kept at or below 41°F through refrigeration or an ice bath, with temperatures checked and recorded.
Dietary staff were observed using the dish machine at a wash temperature of 110 degrees, which did not meet the facility's policy requirement of 120-150 degrees. The required procedure to run several cycles to reach the proper temperature was not followed, resulting in the dishwasher being used at an insufficient temperature.
Surveyors found that three resident rooms were not kept clean and sanitary, with visible debris and dust present for several days. Two residents experienced sleep disturbances due to loud TV noise at night, with complaints documented but unresolved. Additionally, a resident's personal property, including cash and clothing, was not properly accounted for after death, as required by facility policy, and the inventory process was not completed or signed by staff and the family member.
Two residents were involved in a physical and verbal altercation, but the facility's investigation was incomplete, as the assigned LVN only interviewed direct witnesses and the involved residents, without reviewing medical records or consulting other staff. Additionally, the required 5-day investigation report was not submitted to CDPH or the LTC ombudsman, contrary to facility policy and state law.
The facility failed to administer a prescribed inhaler as ordered, did not complete post-seizure vital sign assessments for a resident after multiple seizure episodes, and did not provide a physician-ordered foot cradle for another resident. Nursing staff did not document or perform required actions, and residents confirmed the omissions. Facility policies required these actions to be completed and documented.
A resident who was fully dependent on staff for toileting hygiene waited two hours for assistance after activating the call light, remaining in a soiled brief during the night shift. The resident, who was cognitively intact, reported feeling frustrated and depressed due to the delay. A CNA acknowledged that call lights may not have been answered promptly, despite no reported staffing issues. Facility policy required prompt response to call lights.
A resident was moved from a private room to another room without receiving prior written notice or an explanation, as required by facility policy. The resident was not given the opportunity to acknowledge the change, and no documentation of notification was found in the clinical record, resulting in the resident feeling upset and confused.
Two residents were not properly notified of their Medicare coverage status because their ABN forms were left incomplete, with required options left blank. The Business Office Manager confirmed the forms were not filled out as required, contrary to facility policy that mandates proper notification when Medicare coverage requirements are not met.
A resident left the facility against medical advice without staff being informed of her intention to leave, and there was no documentation of an AMA form, no attempts to discuss the discharge with the resident, and no confirmation of her safety, contrary to facility policy.
A resident was transferred to the hospital on two occasions, but the facility did not provide required notification to the Ombudsman, as confirmed by the DON and absence of fax confirmation. Facility policy mandates timely Ombudsman notification for such transfers, but documentation was lacking.
A resident who had all teeth extracted and was awaiting dentures experienced weight loss and difficulty eating, as the facility did not fully implement the care plan interventions for nutrition. The resident received repetitive meals that were hard to eat, was not included in weekly weight monitoring, and had no specific goal weight set, resulting in inadequate tracking and support for his nutritional needs.
A resident with limited hand mobility was found with unclean teeth and food debris, indicating that oral care had not been provided as required. CNAs confirmed that oral care was missed, despite the resident's care plan and facility policy mandating assistance with daily oral hygiene.
A resident at moderate risk for pressure injuries did not receive required weekly skin assessments, and there was no documentation of repositioning or other preventive interventions. When an open wound was discovered, no wound assessment or monitoring was completed, and no treatment order was initiated. The resident was later hospitalized with an unstageable pressure injury, indicating a failure to follow the facility's pressure ulcer prevention policy.
A resident with contractures and limited mobility did not receive ordered active assisted range of motion (AAROM) exercises because the RNA program was not provided for an extended period. This lapse occurred after a change in the facility's electronic documentation system, which resulted in the resident being omitted from the printed logs used by staff. The issue was confirmed by staff interviews and review of documentation.
A resident assessed as needing supervision for smoking was found with cigarettes and a lighter left unattended at the bedside, contrary to facility policy requiring secure storage of smoking materials. A CNA and the DON confirmed that such items should be locked up, but the resident had access to them without supervision.
A resident with a nephrostomy catheter was found with the collection bag placed on the bed beside her head, above bladder level, despite facility policy and care plan instructions requiring the bag to be kept below the bladder. The resident was unable to reposition the bag due to contractures in both hands, and an LVN confirmed the improper placement during observation.
A resident with orders for pain medications based on pain severity received Tramadol for severe pain and Acetaminophen for moderate pain, contrary to the physician's specified parameters. The resident, who was cognitively intact, reported ongoing pain and insufficient relief, and the nurse did not administer medications according to the prescribed pain scale.
A resident's discharge summary was found to be incomplete when the skin assessment section was left blank, and an LVN confirmed that no skin assessment was performed or documented at discharge. Facility policy requires that discharge summaries include a summary of the resident's status, but this was not followed in this case.
A nurse did not wear a gown while providing wound care to a resident on Enhanced Barrier Precautions, despite clear signage and facility policy requiring both gown and gloves for such procedures. The nurse later acknowledged the omission.
A resident's room was found with three deep scrapes on the wall near the bed and thick debris on the floor. The Maintenance Supervisor was aware of the damage but stated repairs are only made if there is a hole to the next room. No maintenance report or repair was documented for the issue, despite facility policy requiring routine maintenance.
A resident with dementia and neurocognitive disorder developed contractures that were not properly addressed due to the facility's failure to implement its change of condition policy, inaccurate MDS assessments, and lack of care plan updates. Orders for restorative therapy were not clarified when the resident could not participate in active range of motion, and necessary medical equipment, such as a hand splint, was never obtained. Additionally, therapy staff were reported to have falsified documentation regarding therapy time and services provided, resulting in the worsening of the resident's right hand contracture.
Therapy staff failed to provide and accurately document PT, OT, and ST services for multiple residents, with therapy minutes often recorded despite little or no therapy being provided. A resident with a contracture did not receive a needed splint and experienced worsening of the condition. Staff interviews revealed widespread inaccurate documentation, billing for unprovided services, and use of telehealth sessions where therapists were not present or engaged. Several residents were kept on therapy services despite refusals or lack of progress, and therapy goals often did not match residents' actual needs.
A resident with severe cognitive impairment eloped from the facility due to an incomplete elopement risk evaluation. The resident was found across the street, expressing a desire to go home. The evaluation form was missing a critical response, leaving the resident's elopement risk unassessed. Staff interviews confirmed the expectation for complete evaluations, and facility policies emphasized the need for proper risk assessments.
A resident with cognitive communication deficits was left unsupervised in a dining/activity room without access to a call light, leading to an injury to her left eye. Despite her care plan requiring supervision and call light access, staff left her alone, resulting in her being found with a swollen and bruised eye, unable to recall the incident details.
A resident with Alzheimer's, severe cognitive impairment, and a history of falls was not provided the required supervision during toilet transfers, as outlined in their care plan. The facility relied on bed alarms and routine checks rather than direct supervision or a toileting program. This lack of supervision led to the resident falling while attempting to use the bathroom unassisted, resulting in a hip fracture that required hospitalization and surgery.
The facility failed to provide cigarettes to three residents during a scheduled smoking time, violating their rights. The residents, who were cognitively intact, waited for an hour in the designated smoking area, but no staff member distributed the cigarettes as per the facility's policy. The DON confirmed the oversight after reviewing video footage.
A facility failed to report a resident-to-resident altercation to CDPH within 24 hours. The incident involved two residents in a verbal and physical altercation, with one resident claiming to have been run over and punched. Staff interviews confirmed the incident as abuse, but the required SOC 341 form was not submitted. The facility's policy mandates reporting all abuse allegations, but the altercation was not reported to CDPH, the Ombudsman, or the police department.
A resident involved in a physical altercation with another resident sustained a head injury, resulting in a swollen lip and facial discoloration. Despite the facility's policy requiring neurological assessments for head injuries, these checks were not performed. The DON acknowledged the oversight, and the resident, with an intact cognition score, reported pain and swelling from the incident.
A facility failed to develop a care plan for a resident who repeatedly refused care, including changes of briefs and showers. Despite documented refusals over several weeks, the DON could not find a care plan addressing these refusals. The facility's policy requires the interdisciplinary team to assess needs and offer alternatives, which was not done.
A resident with a foul-smelling discharge from the perineal area did not have their change in condition documented, nor was the physician notified, as required by the facility's policy. The DON confirmed the absence of documentation or progress notes for the incident, which could have led to adverse health outcomes.
Failure to Timely Notify Physician and Administer Ordered Antidiarrheal Medication
Penalty
Summary
The facility failed to ensure timely physician notification and appropriate medication administration for a resident experiencing ongoing diarrhea, resulting in a delay in care. The resident had a BIMS score of 8, indicating moderately impaired cognition. Point of Care documentation showed the resident had multiple episodes of loose stools beginning on 2/9/26, with at least three episodes within a 24-hour period by 2/10/26 and continued frequent loose stools on subsequent days. The DON stated that three episodes of loose stools within 24 hours constituted a change of condition and acknowledged that the physician should have been notified on 2/10/26. However, the physician was not notified of the resident’s change in condition until 2/21/26, 11 days after the change of condition occurred, contrary to the facility’s Change of Condition Notification policy requiring timely notification when there is a need to alter treatment due to a change in condition. On 2/21/26 at 8:10 a.m., a CNA informed the charge nurse that the resident had three bowel movements with diarrhea, and the primary clinician recommended loperamide 2 mg every eight hours as needed. The Order Summary Report reflected a physician order for loperamide on 2/21/26. Despite this order and continued documentation of loose stools on 2/21/26 and 2/22/26, the Medication Administration Record showed no loperamide was administered on those dates. The DON confirmed that the loperamide should have been given because the resident continued to have loose stools. On 2/22/26, an alert note documented that the resident requested transfer to an acute hospital due to diarrhea and abdominal pain, and the nurse practitioner ordered the resident to be sent out. The DON stated there was a delay in treatment due to poor communication between the nursing staff.
Failure to Timely Report Alleged Physical Abuse by Family Member
Penalty
Summary
The facility failed to timely report an allegation of abuse involving one resident within the required timeframe. The resident had diagnoses including unspecified dementia, anxiety, Alzheimer’s disease, depression, cognitive communication deficit, and a need for assistance with personal care. An MDS assessment indicated the resident was rarely or never understood, had memory problems, severely impaired decision-making, and required substantial/maximal assistance with eating. A Change in Condition Evaluation dated 2/26/26 documented that a CNA reported witnessing the resident’s sister slap the resident on the right side of the face, with green/yellow discoloration noted on the right cheek upon evaluation. The facility’s 5-Day Investigation Summary indicated that on 2/26/26 the CNA reported having observed the family member strike the resident during a feeding interaction approximately three weeks earlier, on 2/1/26, and acknowledged not reporting the alleged incident to administration at the time it occurred. In an interview, the Administrator confirmed that the CNA did not report the alleged physical abuse until 2/26/26 and acknowledged there was a delay in reporting. In a separate interview, the CNA stated she had immediately informed an LVN on the date of the incident and that the LVN told her to “shut up,” not say anything, and to mind their own business. The LVN stated he did not recall the date and reported that the CNA only told him the resident was being aggressive, denying that the alleged abuse was reported to him. The facility’s abuse policy required immediate reporting of suspected abuse, with specific timeframes of no later than two hours for abuse involving serious bodily injury and no later than 24 hours for other reportable incidents, based on real time rather than business hours.
Failure to Ensure Resident Access to Private Telephone Communication
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had reasonable access to and privacy in their use of telephones and outside confidential communication. The Long-Term Care Ombudsman (LTCO) reported difficulty contacting residents by phone, stating that calls to the facility were often unanswered or routed to voicemail, which he could not use due to the need to maintain confidentiality. On multiple occasions, including several calls made on different days, the LTCO’s calls were answered by the receptionist and then transferred to the nurses’ station, where they went unanswered and were ultimately sent to voicemail. The LTCO stated that, as a result, residents’ rights to private and confidential communications were being violated. Resident 2’s MDS dated 11/19/25 showed a BIMS score of 14, indicating cognitively intact status. Resident 2 reported not having a cell phone and relying on the facility phone to receive calls, and stated that others had told him they called the facility but their calls were not put through to him. A family member of Resident 3 stated that during daytime hours she could reach Resident 3 by phone, but after the receptionist left for the day she could not get anyone on the phone and described it as a “nightmare.” Review of the facility’s Resident Rights policy, revised 10/1/17, showed that residents have the right to privacy and confidentiality in oral, written, and electronic communications and the right to use a telephone in privacy, and that the facility is to ensure residents can exercise their rights without interference.
Failure to Return and Document Resident Personal Belongings at Discharge
Penalty
Summary
The facility failed to ensure a resident received all personal belongings upon discharge, as required to provide a safe, clean, comfortable, and homelike environment. The resident was admitted with documented personal items, including two grey t‑shirts and one white sheet, as recorded on an Inventory List completed at admission. Upon review of the resident’s records after discharge, the Director of Nursing confirmed there was no evidence that the resident’s belongings were provided to the resident or their representative at the time of discharge, nor was there documentation of a signed receipt. The facility’s own Theft Prevention policy required staff to complete a resident inventory at admission and discharge, provide the resident or representative with a copy of the inventory and the resident’s property upon discharge, and obtain a signed receipt, but this process was not documented as having been followed for this resident. The deficiency centers on the lack of documentation and confirmation that the resident’s inventoried personal items were returned at discharge, despite clear policy expectations for securing and accounting for resident property.
Failure to Provide Home Medication List at Discharge
Penalty
Summary
The facility failed to provide a home medication list to a discharged resident as required by its process. During an interview, an LVN stated that at discharge residents are given their medications along with a home medication list that includes instructions on how to take each medication, and that nurses educate the resident on this list and obtain the resident’s signature to confirm the education was completed. However, review of the resident’s Discharge Instruction Form (DIF) dated 12/8/25 showed that while the form indicated medications were provided at discharge and referenced an attachment, no medications were actually listed on the DIF. The DON confirmed there was no evidence that the resident received a home medication list upon discharge. When requested on multiple dates, the facility did not provide a policy and procedure related to this process.
Failure to Provide Required Behavioral Health Interventions and Monitoring
Penalty
Summary
The facility failed to follow its policy and procedure on psychotherapeutic drug management for a resident diagnosed with major depressive disorder and paraplegia. The resident had a history of increased sadness and was prescribed Lexapro, with the dosage recently increased due to verbalized sadness. Despite this, staff did not provide non-pharmacological interventions as required by the care plan and facility policy when the resident expressed increased sadness. Documentation showed that on the day the resident verbalized increased sadness, no non-pharmacological interventions were provided or documented, even though the care plan and physician's order specified such interventions should be attempted prior to medication administration. Additionally, after the increase in Lexapro dosage, the resident was not monitored every shift for 72 hours as required by both the care plan and facility policy. Nursing notes and medication administration records revealed gaps in monitoring, with several shifts lacking documentation of the required checks for side effects, including suicidal ideation. Interviews with staff confirmed that the expected monitoring and documentation did not occur, and that staff relied on CNAs to report any unusual findings rather than conducting direct assessments as required. The failure to provide non-pharmacological interventions and to monitor the resident after a medication change resulted in the resident being found deceased in his room, with evidence of self-harm and no signs of life. The coroner determined the cause of death was neck compression. Staff interviews and record reviews confirmed that the required interventions and monitoring were not implemented or documented, directly leading to the deficiency cited in the report.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment for two residents. One resident reported a strong, foul, and unpleasant smell in his bathroom, which was confirmed by both the resident and housekeeping staff. The housekeeping staff acknowledged that another resident had previously urinated on the bathroom floor, and that the odor was difficult to remove despite cleaning efforts. The smell was described as a combination of urine and bleach. Another resident expressed dissatisfaction with the cleanliness of the shower rooms, stating that the soiled conditions were disgusting. Upon inspection, the housekeeping supervisor confirmed that three out of four shower rooms had dark stains on the tiles, which were identified as buildup from steam. The facility's policy required all rooms to be kept clean and as free as possible from germs and contaminants, while maintaining a pleasant and homelike atmosphere, but these standards were not met in the observed areas.
Failure to Timely Develop Baseline Fall Prevention Care Plans for High-Risk Residents
Penalty
Summary
The facility failed to timely develop baseline care plans with fall prevention interventions for two residents who were identified as high risk for falls upon admission. Both residents had diagnoses including muscle weakness, abnormalities of gait and mobility, and, in one case, Alzheimer's disease. Fall risk assessments conducted at admission indicated high risk scores for both individuals. Despite these findings, no baseline care plan addressing fall prevention was created within the required timeframe for either resident. For one resident, the fall prevention care plan was not developed until 26 days after admission, and for the other, it was created seven days after admission. The Director of Nursing confirmed that both residents were assessed as high risk for falls at admission but acknowledged that baseline care plans with fall prevention interventions were not developed as required. Facility policy mandates that a person-centered baseline care plan be developed within 48 hours of admission, and that nursing staff create a care plan with interventions to reduce fall risk, which was not followed in these cases.
Failure to Maintain Bed in Low Position for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a fall prevention intervention for a resident identified as high risk for falls. The resident, who had diagnoses including Alzheimer's disease, muscle weakness, gait abnormalities, and pain, was assessed with a high fall risk score. The resident's care plan specifically required that the bed be kept in the low position as a safety measure. However, during an observation, the resident was found lying in a bed that was not in the low position, contrary to the care plan and facility policy. A family member expressed concern about the resident's risk of falling, noting that the resident attempted to get out of bed unassisted. A licensed nurse confirmed that the bed was not in the low position and subsequently lowered it. The Director of Nursing also acknowledged that the bed should have been kept low according to the resident's care plan. The facility's fall management policy required beds to be placed in the lowest position as a universal fall prevention measure, which was not followed in this instance.
Failure to Communicate and Address Resident Pain
Penalty
Summary
A resident with Alzheimer's disease, muscle weakness, gait abnormalities, and pain was admitted to the facility and was able to communicate needs despite dementia. During care provided by two CNAs, the resident reported experiencing pain in his arms. The CNAs left the room without providing any pain relief interventions or notifying the licensed nurse responsible for the resident's care. Approximately 40 minutes later, the licensed nurse was informed of the resident's pain only after being approached by surveyors. Upon assessment, the resident reported arm pain at a level five on a zero to ten scale. Facility policy required staff to help residents manage pain and for CNAs to immediately inform the licensed nurse when a resident reports pain, which was not followed in this instance.
Failure to Timely Respond to Call Lights for Two Residents
Penalty
Summary
The facility failed to answer call lights in a timely manner for two residents, resulting in delays in addressing their needs. One resident, who had diagnoses including hemiplegia, hemiparesis, muscle weakness, and incontinence, reported that night staff did not answer the call light and that it took hours for his request to be addressed, specifically when he needed his brief changed. This resident was cognitively intact and expressed feeling ridiculed and helpless due to the delay. His care plan indicated a need for assistance with activities of daily living and incontinence care due to his medical conditions. Another resident, also cognitively intact, reported that it took approximately 45 minutes at night for staff to respond to her call light when she requested water. The Director of Nursing confirmed that waiting 45 minutes to an hour for call light response was not acceptable, especially when residents required assistance with changing briefs or obtaining water. The facility's policy required nursing staff to answer call bells promptly and return to residents with requested items or responses in a timely manner.
Failure to Implement Care Plans for Repositioning and Meal Supervision
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents, resulting in deficiencies related to skin integrity and nutritional supervision. For one resident with a history of pressure injuries, the care plan required repositioning every two hours due to altered skin integrity and a re-opened pressure injury to the sacrococcyx. Observations revealed that the resident remained seated in a wheelchair at a 45-degree angle for an extended period, with staff confirming that the resident had not been repositioned since 11 a.m. The resident was dependent on staff for transfers and mobility, as documented in the Minimum Data Set, and the Director of Nursing acknowledged the care plan's requirement for frequent repositioning. Another resident's care plan indicated the need for supervision and assistance with all meals, as well as staff presence during mealtimes to redirect the resident from feeding others. Observations showed that the resident was eating alone in her room without staff supervision, and a CNA confirmed that no staff were present to assist or monitor the resident during the meal. The Director of Nursing noted that the resident's behavior of feeding others could pose a safety issue, especially for those with swallowing problems. The facility's policy emphasized the importance of care plans in addressing residents' medical, nursing, and psychosocial needs, but these plans were not followed in the observed cases.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines and expectations for quality in nursing services. No additional details regarding specific residents, staff actions, or particular incidents are provided in the report excerpt.
Delayed Call Light Response for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for three of six sampled residents. Observations and interviews revealed that one resident reported call light wait times ranging from five to forty-five minutes, with some staff walking by without responding. This resident used the call light for assistance with brief changes and repositioning due to a pressure injury, and expressed feeling anxious and unwell during long waits, noting that being left wet could worsen her bed sore. The resident calculated wait times by observing a clock in her room. Two additional residents reported call light wait times ranging from twenty minutes to two hours, also using a clock to track the delay. These residents used the call light for brief changes and requests for water or ice water. One resident stated the wait made him angry, while the other expressed significant frustration, stating he called the police due to the delay. Review of the facility's policy indicated that nursing staff are required to answer call bells promptly and courteously, but this was not consistently followed.
Residents Awakened by CNA Singing and Chanting at 4 a.m.
Penalty
Summary
Certified Nursing Assistant (CNA 1) entered the rooms of two cognitively intact residents at approximately 4 a.m., singing and chanting loudly, which resulted in both residents being awakened. Resident interviews confirmed that the CNA's actions disturbed their sleep and were not welcomed, with one resident specifically mentioning the singing and another referencing loud chanting in a foreign language. Both residents expressed that this behavior was disruptive and did not align with their expectations for respectful and dignified care. The Director of Staff Development (DSD) acknowledged receiving previous complaints about CNA 1's behavior, including singing, dancing, and praying during early morning hours. Despite being instructed not to engage in these activities, CNA 1 continued the behavior, stating she was happy and liked to sing. Facility policy requires all staff to treat residents with respect and dignity, and to promote an environment that enhances residents' quality of life. The actions of CNA 1 were inconsistent with these policies, resulting in a failure to honor the residents' rights to a dignified and respectful environment.
Failure to Communicate and Implement Dietitian Recommendations for Resident with Weight Loss
Penalty
Summary
A resident with a diagnosis of mild protein-calorie malnutrition experienced significant weight loss, dropping from 126 lbs to 119 lbs over a ten-day period. The registered dietitian (RD) made recommendations to liberalize the resident's diet by discontinuing the no added salt restriction and to increase the frequency of a nutritional supplement (Boost) from twice to three times daily. These recommendations were documented in the resident's nutrition notes but were not communicated to the physician for approval, nor were they implemented. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the facility's policy and procedure on Assessment and Management of Resident Weights was not followed. The policy required licensed nurses to notify the physician of the RD's recommendations and to document the physician's response, including any refusal and rationale. The DON acknowledged that there was no documentation showing the RD's recommendations were carried out or communicated as required.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Report Missing Narcotic Medications as Required by Facility Policy
Penalty
Summary
The facility failed to follow its own policy and procedure regarding Unusual Occurrence Reporting when missing narcotic controlled medications were not reported to the California Department of Public Health (CDPH). On 6/18/25, it was discovered that four oxycodone, four Percocet, and four Norco tablets were missing from the emergency kit (E-kit), which contains a pre-determined supply of medications, including controlled substances, for immediate patient needs. Despite this discovery, the incident was not reported to CDPH as required by the facility's policy. During interviews and record reviews, the Director of Nursing (DON) confirmed the discovery of the missing narcotics, and the Administrator acknowledged that the facility had not reported the incident, even though the policy clearly states that such occurrences must be reported to the appropriate state or federal agencies within 24 hours by telephone and then confirmed in writing. The policy also specifies that allegations of misappropriation of resident property and other occurrences affecting the welfare, safety, or health of residents, employees, or visitors must be reported. The failure to report the missing narcotics was a direct violation of the facility's established procedures.
Failure to Administer and Monitor Narcotic Pain Medication per Physician Orders
Penalty
Summary
The facility failed to administer narcotic pain medication according to the physician's orders for one resident. The resident, who had diagnoses including osteomyelitis, complete traumatic amputation of the left lower leg, unspecified pain, and inguinal hernia, had a physician's order for Norco 5-325 mg to be given by mouth every 12 hours as needed for pain levels between 4 and 10 on the pain scale. However, the Medication Administration Record (MAR) showed that Norco was administered on multiple occasions when the resident's pain scale was documented as 0, which was outside the prescribed parameters. Additionally, there was no documentation of reassessment or re-evaluation of the effectiveness of the narcotic medication after administration on several dates. The facility's pain management policy required licensed nurses to assess and document pain and the resident's response to interventions, but this was not done as required. The Director of Nursing confirmed that the medication was given outside the ordered parameters and that reassessment documentation was missing.
Medications Improperly Left at Bedside for Residents Not Authorized for Self-Administration
Penalty
Summary
Surveyors identified a deficiency in the facility's medication management practices, specifically regarding the storage and administration of drugs and biologicals. During multiple observations, medications were found left on the bedside tables of six residents who did not have orders or documented capability for self-administration. These medications included ointments, tablets, inhalers, and controlled substances such as methadone. Nursing staff, including LVNs and RNs, confirmed during interviews that these residents were not capable of self-administering medications and should not have had access to them at their bedside. Record reviews for each resident showed that self-administration assessments had been completed, and all indicated that the residents were not capable of self-administering or securely storing their medications. Despite this, medications were left within reach of the residents, contrary to facility policy and professional standards. Staff interviews consistently acknowledged that medications should not be left at the bedside, and that the observed situations were not in compliance with facility procedures. The facility's policies on drug storage and medication administration require that drugs and biologicals be stored securely and not left at the bedside unless a resident is assessed and authorized for self-administration. The failure to adhere to these policies resulted in medications being accessible to unauthorized individuals, as confirmed by both direct observation and staff interviews.
Milk Served Above Safe Temperature
Penalty
Summary
The facility failed to ensure that milk served to residents was maintained at the appropriate temperature, as required by both facility policy and food safety standards. During an observation in the kitchen, the milk temperature was measured at 46 degrees Fahrenheit, which exceeds the facility's policy requirement of less than 41 degrees. This was confirmed during a test tray delivery, where the Dietary Manager also recorded the milk temperature at 46 degrees and acknowledged it was above the acceptable limit. Facility policies reviewed indicated that milk should be kept at or below 41 degrees, either by refrigeration or by using an ice bath during meal service, and that temperatures should be checked and recorded. The failure to maintain proper milk temperature was directly observed and confirmed through staff interview and record review.
Dishwasher Operated Below Required Temperature
Penalty
Summary
Surveyors observed that dietary staff operated the facility's dishwasher at a wash temperature of 110 degrees, which was below the required range of 120-150 degrees as specified in the facility's policy and procedure for dish machine temperature recording. This was confirmed during two separate observations and interviews with dietary aides while the dishwasher was in use. The facility's policy required allowing the dish machine to run through several cycles to bring the water temperature up to the proper level, but this procedure was not followed, resulting in the dishwasher operating at an insufficient temperature.
Deficiencies in Cleanliness, Noise Control, and Protection of Resident Property
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in three resident rooms, as observed by surveyors. In one room, thick debris and dust, including white particles, were found under the beds and on the sliding door frame, with a resident present in the room. Housekeeping staff acknowledged the dust and debris, and another resident reported that dirt, food wrappers, and dust had been present for several days. Facility policy required regular sweeping, mopping, or vacuuming of all floors, which was not followed in these instances. Noise levels in the facility were not kept at a comfortable level for two residents. One resident reported being unable to sleep due to another resident's TV being excessively loud at night, resulting in headaches and the need for medication. The issue was documented in a grievance report, and another resident also reported sleep disturbances due to a roommate's loud TV. Staff interviews confirmed awareness of the complaints, but the issue remained unresolved at the time of the survey. Facility policy emphasized the importance of maintaining comfortable noise levels in resident rooms. The facility also failed to protect a resident's personal property after the resident's death. A family member reported that clothing and $620 in cash were missing when collecting the resident's belongings. The inventory list completed at admission included these items, but at discharge, the inventory was not completed or signed by staff and the family member, as required by facility policy. The policy mandated that all property be accounted for and a signed receipt obtained upon discharge or death, which did not occur in this case.
Failure to Conduct Thorough Abuse Investigation and Timely Reporting
Penalty
Summary
The facility failed to follow its Elder Abuse Prohibition and Prevention policy and procedure in response to a resident-to-resident physical and verbal altercation involving two residents. The investigation was incomplete, as the staff member assigned to investigate, an LVN, only interviewed the staff witnesses and the residents directly involved. The LVN did not interview other residents, review the medical records of the involved residents for prior history of aggression or behaviors, or speak to other staff who had provided care to the residents before the incident. The LVN also stated she was not trained to investigate abuse and was only instructed to interview witnesses and the involved residents. The documentation was limited to statements on the SOC 341 form, without a comprehensive review as required by facility policy. Additionally, the facility did not submit a 5-day investigation report to the California Department of Public Health (CDPH) or the LTC ombudsman, as required by both facility policy and state law. The administrator confirmed that such reports were not sent, indicating a failure to report the results of the investigation to the appropriate authorities within the mandated timeframe. This omission resulted in the potential for an incomplete investigation and lack of protection for the residents involved.
Failure to Follow Physician Orders and Complete Required Assessments
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for one resident. During medication pass, a nurse was unable to locate the prescribed Albuterol inhaler for a resident with chronic obstructive pulmonary disease and did not administer the 9 a.m. dose as ordered. The nurse did not notify the physician about the missed dose, and the medication was still not given nearly three hours later. The resident, who was cognitively intact and receiving oxygen, confirmed that the breathing treatment had not been received as scheduled. Facility policy required that medication errors, including omissions, be reported to the Director of Nursing, attending physician, and administrator. The facility also failed to complete vital sign assessments after seizure episodes for another resident. A family member reported that the resident appeared distressed and had a fever prior to experiencing multiple seizures. Documentation showed that vital signs were only taken before the seizures, with no record of vital signs or temperatures being taken after the episodes. Nursing staff confirmed that post-seizure vital signs were not documented or performed, and the Director of Nursing acknowledged that documentation of seizure times and post-episode vital signs was missing. Facility policy required that vital signs be obtained and recorded after seizure activity, along with detailed documentation of each episode. Additionally, the facility did not follow physician orders for the use of a foot cradle for a resident with a wound. The resident reported never having a foot cradle, and nursing staff confirmed that the device was not in use, despite a standing physician order for its use every shift. Review of facility policy indicated that supplies and equipment required to carry out physician orders should be provided and verified for completeness and accuracy.
Delayed Call Light Response Resulting in Prolonged Exposure to Soiled Brief
Penalty
Summary
The facility failed to ensure that a resident's call light was answered in a timely manner, resulting in the resident waiting for two hours in a soiled brief during the night shift. The resident, who was alert, oriented, and cognitively intact with a BIMS score of 15, was fully dependent on staff for toileting hygiene according to the Minimum Data Set. The resident reported feeling frustrated and depressed due to the prolonged wait, and verified the duration using her cell phone. A CNA working the night shift confirmed that call lights may not have been answered promptly, despite having no reported staffing issues and being responsible for 12-14 residents. Facility policy required nursing staff to answer call bells promptly and courteously.
Failure to Provide Written Notice Prior to Room Change
Penalty
Summary
A resident was admitted to the facility and initially placed in a private room. Approximately one week later, after returning from a shower, the resident found staff collecting his belongings and was informed that he was being moved to another room. The resident reported that he was not notified in advance of this decision and did not sign any acknowledgment regarding the room change. This unexpected move caused the resident to feel upset and confused. A review of the resident's clinical record by the Social Services Director confirmed there was no documentation of written notification provided to the resident about the room change, nor was there a documented reason for the move. The facility's policy and procedure require that residents receive timely, written notice—including the reason for the change—prior to any room or roommate assignment changes. The policy also states that such information should be documented in the resident's medical record. These steps were not followed in this instance.
Failure to Complete Advanced Beneficiary Notice of Non-coverage (ABN) Forms
Penalty
Summary
The facility failed to ensure that the Advanced Beneficiary Notice of Non-coverage (ABN) was properly completed for two of three sampled residents. During interviews and record reviews with the Business Office Manager, it was found that the ABN forms for both residents had the required options section left blank, indicating that the residents had not selected or been assisted in selecting one of the available choices regarding their Medicare coverage and potential financial responsibility. The Business Office Manager confirmed that the ABNs were incomplete. Review of the facility's policy indicated that Medicare beneficiaries should be properly notified when they do not meet requirements for covered skilled services, but this process was not followed for the two residents involved.
Failure to Follow AMA Discharge Policy and Documentation
Penalty
Summary
The facility failed to follow its policy and procedure for Discharge Against Medical Advice (AMA) for one resident. According to the discharge summary, the resident was discharged AMA, but there was no documentation of an AMA form in the resident's chart, no evidence of attempts to discuss the discharge with the resident, and no documentation confirming the resident's safety upon leaving. Interviews with staff revealed that the resident left the facility without informing staff of her intention to leave or dissatisfaction with care, and staff only became aware of her absence after she had already exited the building. The facility's policy required staff to attempt to encourage the resident to remain for continued treatment and to have the resident review and sign an AMA form upon discharge, neither of which occurred in this case.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's transfer to the hospital on two separate occasions, as required by facility policy. During an interview and record review with the DON, it was confirmed that there was no fax confirmation or other documentation to show that the Ombudsman had been notified when the resident was transferred to an acute care facility. The facility's policy states that notification to the Ombudsman must occur as soon as practicable for facility-initiated discharges, including temporary transfers to hospitals. This lack of documentation and notification was identified through review of the resident's discharge summaries and facility procedures.
Failure to Implement Individualized Nutrition Care Plan After Dental Extraction
Penalty
Summary
The facility failed to implement a complete and individualized care plan for a resident who had recently undergone full dental extraction and was awaiting dentures. The resident expressed concerns about weight loss and difficulty eating due to the lack of teeth. Despite these concerns, the care plan interventions, which included honoring food choices, monitoring food intake, offering substitutes for refused foods, and updating food preferences, were not fully carried out. The resident reported receiving repetitive meals such as sandwiches and chicken soup, which were difficult to eat, and was unaware of alternative food options available to him. Record reviews showed that the resident was not included in the weekly weight monitoring for two consecutive months, and his meal intake consistently remained below 75%. The care plan lacked a specific goal weight, making it difficult to assess whether nutritional goals were being met. Documentation confirmed a one-pound weight loss over the period in question, and the resident's meal ticket did not reflect his updated food preferences. These findings indicate that the facility did not ensure the care plan was effectively implemented to address the resident's nutritional needs following his dental procedure.
Failure to Provide Oral Care to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with contractures in both hands was observed in bed with food particles between her teeth, brownish discoloration, and several missing teeth. Certified Nursing Assistants (CNAs) interviewed acknowledged that the resident's teeth appeared not to have been brushed for days, and one CNA admitted to not returning to provide oral care after finding the resident asleep. The resident's care plan required setup and assistance with oral care, and the facility's policy stated that residents with teeth should have them brushed twice daily. Despite these directives, oral care was not provided as required.
Failure to Implement Pressure Ulcer Prevention Policy Resulting in Pressure Injury
Penalty
Summary
The facility failed to implement its policy and procedure for pressure ulcer prevention for one resident, resulting in the development of a pressure injury on the coccyx area. Multiple interviews and record reviews revealed that required weekly skin assessments were not completed or documented, including on the weekly summary and shower sheets. Both the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) confirmed that skin assessments were missing for several dates, and there was no documentation of interventions such as repositioning for a resident identified as being at risk for pressure injuries. The resident in question had a history of being at moderate risk for pressure injuries, as indicated by a Braden score of 17, and was noted to be chairfast, very moist, and requiring partial to moderate assistance with mobility and hygiene. Despite these risk factors, there was no evidence that the care plan addressed necessary interventions such as moisture control, pressure reduction, or repositioning. Additionally, there was no documentation that the resident received education on the causes and prevention of pressure injuries. When an open wound was eventually discovered on the resident's buttocks, there was no wound assessment, measurement, or wound monitoring record completed, and no treatment order was initiated. The facility's policy required immediate implementation of a wound monitoring record and care plan revision upon identification of a wound, but these steps were not taken. The resident was later admitted to the hospital with an unstageable pressure injury, further confirming the lack of appropriate preventive and responsive care.
Failure to Provide Ordered Restorative Nursing Program Due to Documentation System Change
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order to provide a Restorative Nursing Assistant (RNA) program for a resident with contractures in both hands and limited mobility. The resident reported not receiving exercises or being out of bed for some time. Review of the resident's Order Summary Report showed an active order for RNA staff to perform active assisted range of motion (AAROM) exercises to both lower extremities three times per week, once daily, as tolerated. However, the Restorative Nursing Assessment Log indicated that no RNA program was provided to the resident for an 11-day period, and the assigned RNA confirmed that she had not performed the exercises due to lack of access to the electronic health record system and the resident not being included in the printed log used for tracking RNA services. Further interviews revealed that a recent change in the facility's electronic documentation system resulted in the RNA program orders not being accessible or printed for staff, leading to the resident being missed for the entire month. The Director of Staff Development acknowledged the issue, stating that the transition to a new software system disrupted RNA access and that paper logs were being used temporarily. Facility policy required the RNA to carry out the restorative program according to the care plan and document daily, but this was not followed for the resident in question.
Unsupervised Access to Smoking Materials
Penalty
Summary
A deficiency occurred when a resident who was assessed as requiring supervision for smoking was found with a pack of cigarettes and a lighter on the bedside table, accessible and unattended. Certified Nursing Assistant (CNA) 12 confirmed that smoking materials are supposed to be locked at the nurses' station and not left with residents. During an interview, the resident stated that her cigarettes and lighter were in her purse, which was in her lap at the time. The Director of Nursing (DON) reiterated to the resident that facility policy requires smoking articles to be locked up. Review of the resident's Smoking Assessment indicated the need for supervision, and facility policy mandates that all smoking materials be stored securely based on individual assessments. Despite these requirements, the resident had unsupervised access to smoking materials.
Improper Placement of Nephrostomy Catheter Collection Bag
Penalty
Summary
A nephrostomy catheter collection bag for Resident 28 was observed placed on the bed beside the resident's head, positioned higher than the level of the bladder, while the resident was lying upright in bed. The collection bag contained yellowish urine-like liquid. The resident had contractures in both hands, rendering her unable to lift or move objects. During the observation, an LVN confirmed that the catheter bag should be placed lower than the bladder. The resident's care plan indicated monitoring of the nephrostomy drain and its site, and the facility's policy specified that collection bags must always be kept below the level of the bladder, including during transport.
Failure to Administer Pain Medication According to Physician Orders
Penalty
Summary
The facility failed to follow the physician's orders for pain management for one resident. Specifically, the resident had physician orders for Tramadol to be administered for moderate pain (pain rating 4-6) and Acetaminophen for mild pain (pain rating 1-3). However, documentation showed that Tramadol was administered when the resident reported severe pain (pain ratings of 7 and 8), and Acetaminophen was given when the resident reported moderate pain (pain rating of 4). During observation, the resident was noted to be moaning and reported a pain level of over 10, while the nurse prepared to administer Tramadol, which was not in accordance with the prescribed pain scale parameters. The resident, who was cognitively intact according to the MDS assessment, reported that Tramadol provided only partial relief and that her pain would return. The facility's policy required licensed nurses to administer pain medication as ordered, but the records and interviews indicated that pain medications were not consistently given according to the specified pain rating parameters. This resulted in the resident experiencing unrelieved pain and pain management that did not align with the physician's orders.
Incomplete Discharge Summary Due to Missing Skin Assessment
Penalty
Summary
The facility failed to complete a discharge summary for one resident, as required by its own policy and accepted professional standards. During a review of the resident's discharge summary, it was found that the section for skin assessment was left blank, indicating that no skin assessment was completed at the time of discharge. This was confirmed during an interview with an LVN, who stated that the skin assessment was not performed or documented. The facility's policy specifies that a discharge summary must include a summary of the resident's status, including a description of medically defined conditions and prior medical history, but this requirement was not met in this instance.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to wear a gown while providing wound care to a resident who was under Enhanced Barrier Precautions. The resident had signage above the bed indicating that both a gown and gloves were required during any wound care involving a dressing. The LVN acknowledged after the procedure that a gown should have been worn. Review of the facility's policies confirmed that staff are required to wear appropriate personal protective equipment, including gowns, when performing tasks likely to soil clothing with blood, body fluids, secretions, or excretions. The policies also specify that Enhanced Barrier Precautions require targeted gown and glove use during high-contact resident care activities, such as wound care, to reduce the transmission of multidrug-resistant organisms.
Failure to Maintain Resident Room in Good Repair
Penalty
Summary
The facility failed to maintain a resident's room in good repair, as evidenced by three deep scrapes on the wall by the head of the bed and thick debris on the floor. During observation, a resident was found lying in bed in this room. The Maintenance Supervisor acknowledged awareness of the scrapes, stating that repairs are not made unless there is penetration through to the next room. Review of the facility's maintenance concerns list showed no report or repair for the damaged wall, despite the facility's policy requiring routinely scheduled maintenance service to all areas.
Failure to Implement Change of Condition Policy, Inaccurate MDS, and Inadequate Therapy Documentation
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate treatment and care for a resident with dementia and neurocognitive disorder with Lewy bodies. The facility did not implement its policy and procedure for change of condition when the resident developed contractures, as therapy documented the onset of contractures but no notification was made to the physician or family, and no change of condition process was initiated. The resident's Minimum Data Set (MDS) assessments were also inaccurate, as they did not reflect the presence of contractures, and the care plan was not updated to address the new condition. The resident was dependent for all activities of daily living and unable to communicate, with increased risk for contractures, but these changes were not properly documented or addressed in the care plan or MDS. Further deficiencies were identified in the provision of restorative and therapy services. Physician orders for both active and passive range of motion (AROM and PROM) were not accurately reflected in practice, as the resident was unable to participate in AROM but the order was not clarified or updated. The Restorative Nursing Assistant (RNA) continued to provide PROM only, without raising the issue of the inappropriate order. Additionally, the facility failed to obtain necessary medical equipment, specifically a hand splint for the resident's right hand contracture, despite therapy recommendations and care plan directives. There was no documented request for the splint, and the resident never received it, resulting in worsening of the contracture. Documentation practices were also found to be deficient. Therapy staff, including occupational and physical therapists, were reported to have falsified documentation regarding the amount of time spent with residents and the provision of therapy services. Multiple staff interviews and email statements indicated that therapy was not provided as documented, with some residents not being seen as required, and therapy notes being completed without actual resident contact. These failures in documentation, assessment, and care delivery contributed to the resident's decline, specifically the worsening of the right hand contracture.
Failure to Provide and Accurately Document Rehabilitative Therapy Services
Penalty
Summary
The facility failed to provide and accurately document specialized rehabilitative services, including physical therapy (PT), occupational therapy (OT), and speech therapy (ST), as required for multiple residents. Therapy staff inaccurately documented the time spent providing therapy to all 11 sampled residents, with several instances where therapy minutes were recorded despite therapy not being provided, or where the actual time spent was significantly less than documented. Interviews with staff and residents revealed that therapy sessions were often much shorter than recorded, and in some cases, residents reported not receiving therapy at all despite documentation to the contrary. There were also reports of therapy staff being asked to falsify documentation, and of therapy being billed for residents who refused or did not participate in therapy. One resident with dementia and a neurocognitive disorder with Lewy bodies was ordered to receive OT twice a week to reduce the risk of contractures and skin breakdown. Documentation showed inconsistent and insufficient therapy minutes, and the resident did not receive a needed splint for a right hand contracture, which subsequently worsened. Other residents reported therapy sessions lasting only five to ten minutes, despite documentation of much longer sessions. Several residents were documented as receiving therapy even when they refused or were unavailable, and some therapy notes were completed without the therapist being present or providing care. Staff interviews confirmed that therapy services were not provided as ordered, and that documentation was often completed to reflect compliance with orders rather than actual care provided. Multiple staff members, including therapy assistants and technicians, reported concerns about fraudulent documentation and billing practices, including the use of telehealth sessions where therapists were not focused on the resident or were not present at all. There were also reports of residents being kept on therapy services despite not meeting criteria, and of therapy goals and evaluations not matching the residents' actual conditions. These failures resulted in at least one resident experiencing harm, with the potential for negative impact on the physical conditions of others.
Incomplete Elopement Risk Evaluation Leads to Resident Elopement
Penalty
Summary
The facility failed to complete an elopement risk evaluation for a resident, which resulted in the resident eloping from the facility. The resident was found across the street from the facility, repeatedly expressing a desire to go home. The elopement risk evaluation form for the resident, dated February 27, 2025, was incomplete, as a critical question regarding the resident's expressed desire to go home was left unanswered. This omission meant that the resident's level of elopement risk was not properly assessed. Interviews with facility staff revealed that the registered nurse acknowledged the incomplete evaluation and stated that all questions should have been answered. The Director of Nursing also confirmed that the expectation was for nurses to complete the entire elopement evaluation form. The resident's Minimum Data Set, dated March 1, 2025, indicated a severe cognitive impairment with a BIMS score of 0 and noted the resident's use of a walker. The facility's policies on elopement risk reduction and wandering and elopement, dated June 2017, emphasized the importance of identifying residents at risk of elopement and assessing them upon admission.
Resident Left Unsupervised, Resulting in Injury
Penalty
Summary
The facility failed to follow the care plan for a resident with a cognitive communication deficit, resulting in the resident being left unsupervised in the dining/activity room without access to a call light. This oversight led to the resident sustaining an injury to her left eye under unknown circumstances. The resident, who has a history of chronic obstructive pulmonary disease, muscle wasting, cognitive communication deficit, and reduced mobility, was found with bruising and swelling on her left eye, which she attributed to being struck by an unidentified male. On the day of the incident, the resident was taken to the dining/activity room by an LVN, who left her there unsupervised. Approximately 15 minutes later, the resident was discovered by a CNA with a swollen and bruised left eye, crying and unable to recall the details of the incident. The resident's care plan specifically required that call lights be within reach and that she not be left alone, especially given her communication difficulties and the absence of call lights in the dining/activity room. Interviews with staff, including CNAs and the Director of Nursing, confirmed that the resident should not have been left alone due to her inability to communicate effectively and the lack of call lights in the room. The failure to adhere to the care plan and provide necessary supervision and safety measures directly contributed to the resident's injury and the potential for further negative health outcomes.
Failure to Provide Supervision During Toilet Transfers Resulting in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when the facility failed to implement the care plan intervention of providing supervision during toilet transfers for a resident with Alzheimer's Disease, generalized muscle weakness, a history of falls, and severe cognitive impairment. The resident required assistance and supervision with personal hygiene, toileting, and transfers, as documented in the care plan and Minimum Data Set (MDS). Despite these documented needs, the resident was able to get up unsupervised to use the toilet, resulting in a fall in her room. The facility's Fall Prevention Care Plan included interventions such as keeping the call light within reach, encouraging the resident to use it for assistance, and using a pressure pad alarm to alert staff when the resident attempted to get up unassisted. However, the Fall Risk Evaluation was incomplete, with several sections left blank, and did not specify interventions such as assistance with ambulation and transfers or a toileting program. On the day of the incident, there was no documentation that the resident was provided supervision or assistance with toileting, and the resident was not on a scheduled toileting program. Staff relied on a bed alarm and routine two-hour checks, but there was no documentation of monitoring, and the alarm was reportedly not heard by another resident in the room at the time of the fall. As a result of the lack of supervision and incomplete implementation of the care plan, the resident sustained a fall with a left femoral neck fracture, requiring hospital admission and surgical intervention. Facility policies required that care plans address the needs identified in assessments and that residents at risk for falls receive appropriate monitoring and supervision, but these were not fully implemented for this resident.
Failure to Provide Cigarettes During Scheduled Smoking Time
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the distribution of cigarettes to residents during scheduled smoking times, resulting in a violation of resident rights. Three residents, who were cognitively intact as confirmed by their Minimum Data Set (MDS) assessments, were not provided cigarettes during the scheduled smoking time on a specific day. These residents waited outside in the designated smoking area for approximately one hour, but no staff member came to distribute the cigarettes as per the facility's policy. Interviews with the residents revealed their frustration and disappointment due to the lack of adherence to the smoking schedule. The Licensed Vocational Nurses (LVNs) confirmed that cigarettes were kept locked in a medication cart and were supposed to be distributed by an assigned staff member. The Director of Nurses (DON) reviewed video footage confirming the residents' wait and acknowledged that the residents should have been given cigarettes as per the facility's policy. The facility's policy on resident rights explicitly includes the right to smoke, which was not honored in this instance.
Failure to Report Resident Altercation to CDPH
Penalty
Summary
The facility failed to report an allegation of a resident-to-resident altercation to the California Department of Public Health (CDPH) within the required 24-hour timeframe. The incident involved two residents, where one resident claimed that the other had run over her foot and punched her in the face. Although the resident later denied physical contact, a witness confirmed that there was an attempt to punch and some contact was made. The altercation was characterized by loud verbal exchanges and inappropriate language, which was considered verbal abuse. Interviews with staff, including a Registered Nurse (RN), Licensed Vocational Nurse (LVN), Social Services Director (SSD), and the Director of Nursing (DON), revealed that the incident was recognized as abuse and should have been reported to CDPH. The facility's policy mandates reporting all allegations of abuse to the state agency immediately or within 24 hours. However, the SOC 341 form, which documents suspected abuse, was not faxed to CDPH, indicating a failure to adhere to the facility's abuse reporting policy. The facility's Administrator, who serves as the abuse coordinator, acknowledged that the altercation was not reported as required. The facility's policy emphasizes the residents' right to be free from mistreatment and mandates reporting all alleged violations to the appropriate authorities. Despite this, the altercation between the two residents was not reported to CDPH, the Ombudsman, or the police department, as required by state law and the facility's policy.
Failure to Conduct Neurological Assessments After Resident Altercation
Penalty
Summary
The facility failed to implement its policy and procedure for conducting neurological assessments for a resident who sustained a head injury. During an incident on 11/9/24, Resident 1 was involved in a physical altercation with another resident, resulting in a swollen lip and discoloration to the left side of her face. Despite the facility's policy requiring neuro checks for any resident with a head injury, these assessments were not performed for Resident 1. The Director of Nursing acknowledged the oversight during a review of Resident 1's electronic medical record. Resident 1, who had an intact cognition score of 15 on the Brief Interview for Mental Status, reported being struck in the face and head by another resident, causing pain and swelling. An observation conducted on 11/20/24 confirmed the presence of grayish to yellowish discoloration on Resident 1's face and lip. The facility's policy, dated 10/14/15, mandates neurological assessments for any resident with a head injury, but this protocol was not followed in Resident 1's case, potentially leading to adverse health outcomes.
Failure to Develop Care Plan for Resident's Refusal of Care
Penalty
Summary
The facility failed to develop a care plan for a resident who repeatedly refused care, including changes of briefs and showers. The Resident Daily Care Flowsheet documented multiple instances of the resident's refusal to be changed or bathed over a period from early March to mid-April. Despite these documented refusals, the Director of Nursing was unable to find any documentation of a care plan addressing the resident's refusal of care. The facility's policy and procedure on refusal of treatment, dated May 1, 2023, requires the interdisciplinary team to assess the resident's needs and offer alternative treatments while continuing to provide other services in the care plan. However, this was not implemented for the resident in question.
Failure to Document and Notify Physician of Change in Condition
Penalty
Summary
The facility failed to address a change in condition for one of the sampled residents, identified as Resident 1, who exhibited a foul-smelling discharge from the perineal area. Upon reviewing Resident 1's Daily Care Flowsheet dated February 12, 2023, it was noted that there was no documentation of this change in condition, nor was there any notification to the physician regarding the abnormal findings. During an interview and record review with the Director of Nursing (DON) on September 19, 2024, it was confirmed that there was no documentation or progress/nursing notes for Resident 1 on the specified date. The facility's policy and procedure on 'Change of Condition,' dated October 15, 2015, mandates that all changes in a resident's medical condition must be recorded in the medical records and that notification should be made within 24 hours. The lack of documentation and notification had the potential to result in adverse health outcomes for Resident 1.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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