Imperial Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Studio City, California.
- Location
- 11441 Ventura Blvd, Studio City, California 91604
- CMS Provider Number
- 555707
- Inspections on file
- 70
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Imperial Care Center during CMS and state inspections, most recent first.
A resident with COPD, heart failure, muscle weakness, dysphagia, and moderate cognitive impairment was started on prednisone 20 mg daily for cough per a telephone order. Despite this new steroid therapy, facility staff did not develop or implement a person-centered care plan addressing the medication, including goals or interventions such as monitoring for side effects or vital sign changes. The ADON confirmed that no care plan was created for the prednisone use, which was not consistent with the facility’s policy requiring comprehensive, data-driven care plans with measurable objectives and timetables that are revised as resident conditions change.
Nursing staff failed to complete and document a timely admission assessment for a resident with multiple psychiatric diagnoses upon re-admission. The assigned RN did not perform the required assessment, instead passing the responsibility to other staff, resulting in the assessment being delayed until the following shift. This was not in accordance with facility policy, which requires immediate assessment and documentation upon admission or re-admission.
A CNA trainee reported witnessing abuse by another CNA, including residents being left in urine and rough treatment. The DSD received the allegation and informed the ADMIN, but the incident was not reported to the SSA within the required two-hour timeframe, and no immediate investigation or suspension occurred, contrary to facility policy.
A nurse prepared to administer Gabapentin to a resident without checking the required respiration rate as ordered by the physician. The nurse was stopped by a surveyor before giving the medication, and later admitted the parameter was not checked immediately prior to administration. The DON confirmed this was a significant medication error, as facility policy requires adherence to physician orders for medication administration.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors during their review of documentation and information handling practices.
A nurse failed to perform hand hygiene before preparing Gabapentin for a resident with dementia and neuropathy, directly handling medication capsules without washing hands or using sanitizer, contrary to facility policy. The nurse had previously touched doorknobs and other surfaces before medication preparation, and the DON confirmed that hand hygiene is required before handling medications.
A CNA assisted a resident with dementia and other conditions by standing over them during a meal, rather than sitting at eye level as required by facility policy. The CNA admitted to not using the available chair, and the DON confirmed that this practice does not respect the resident's right to dignity. Facility policy specifies that meal assistance should be provided in a manner that ensures safety, comfort, and dignity, including not standing over residents.
The facility did not develop or implement comprehensive care plans for several residents, including the use of alarms for fall prevention, management of behaviors related to alarm removal, administration of psychotropic medications, and monitoring of antibiotic therapy. Staff confirmed the absence of required care plans for these interventions, despite facility policy and physician orders.
Nursing staff did not follow physician orders and facility policy for two residents, including failing to monitor and document orthostatic hypotension and neurochecks after a fall for a resident with multiple diagnoses, and failing to rotate insulin injection sites for a resident with diabetes. These actions were confirmed by nursing leadership and staff as not meeting professional standards of practice.
Several residents with cognitive impairment and high fall risk were not provided with required safety interventions, including functional pad alarms and proper placement of fall mats, and one resident had unauthorized access to medication at the bedside. These deficiencies were confirmed through staff interviews, observations, and review of facility policies.
A nurse administered several morning medications to a resident earlier than the scheduled time and failed to document the actual time of administration in the MAR, instead recording them as given at the scheduled time. This action was not in accordance with facility policy, which requires medications to be given within one hour of the scheduled time and documented immediately after administration.
A nurse administered three medications to a resident earlier than the scheduled time and failed to document the early administration, resulting in a medication error rate of 12%. The nurse did not follow facility policy requiring medications to be given within one hour of the scheduled time and to document any deviations, leading to multiple medication errors for a resident with complex medical needs.
Multiple nurses failed to rotate insulin injection sites when administering insulin to a resident with diabetes, despite physician orders and facility policy requiring site rotation. This repeated action over several occasions led to a significant medication error, as confirmed by both the LVN and DON.
Surveyors found that the facility failed to properly label and date food items in kitchen refrigerators and freezers, did not maintain clean and sanitary kitchen and storage areas, and did not remove dented cans from food storage shelves as required by policy. These deficiencies were confirmed through staff interviews and direct observation, with multiple instances of unlabeled or mislabeled food, unclean surfaces, and improper storage of damaged goods.
Surveyors found that staff failed to maintain accurate and complete clinical records, including inconsistent documentation of an Advance Directive for a resident, inaccurate recording of medication administration times by an LVN, and incomplete informed consent forms for psychotropic medications for two residents. These actions did not align with facility policies and accepted professional standards.
Surveyors identified multiple infection control deficiencies, including an LPN failing to disinfect a medication tray between use for two residents, the use of permeable mesh covers on linen carts instead of non-permeable covers, and a staff member storing a personal water container inside a linen cart with clean linens. These actions were inconsistent with facility policies and had the potential to contribute to the spread of communicable diseases.
Several residents receiving antibiotics for infections were not properly monitored for adverse effects or medication effectiveness, despite physician orders and care plans requiring such monitoring. Documentation was lacking for multiple days during antibiotic administration, and staff confirmed that monitoring was not performed as required by the facility's antibiotic stewardship policy.
Three residents with severe cognitive impairment and high fall risk were found with unsafe electrical equipment, including a nonfunctional bed alarm with a broken sensor cord and two bed remote controls with frayed or exposed wires. Staff and maintenance confirmed the equipment was not properly checked or reported, despite facility policies requiring a safe environment.
Three residents with cognitive impairment and high fall risk were subjected to physical restraints, including a bed placed against the wall and pad/tab alarms, without obtaining a physician's order, informed consent, or conducting a restraint assessment. Staff confirmed that these interventions were implemented without following required procedures or developing appropriate care plans.
A resident with muscle weakness, impaired vision, moderate cognitive impairment, and a high risk for falls did not have their call light within reach, as it was found on the floor during observation. Staff confirmed the call light should always be accessible, and facility policy requires residents to have a means to call for assistance from their bed and other areas.
A resident with multiple diagnoses, including depression and dementia, was prescribed psychotropic medications without the required quarterly interdisciplinary team (IDT) review to assess the ongoing need for these medications. Facility staff confirmed that the last behavioral IDT was completed at admission, and no subsequent quarterly reviews were documented, contrary to facility policy. This lapse meant the resident's medication regimen was not regularly evaluated by the IDT as required.
A resident with cognitive impairment and multiple medical conditions alleged being pushed by another resident, resulting in a serious hip fracture. Despite clear statements from the injured resident, staff present did not report the abuse allegation to the DON or ADM as required, and the incident was not reported to CDPH, the ombudsman, or law enforcement within the mandated two-hour timeframe. The facility's policy for reporting abuse was not followed, leading to a delay in investigation and notification.
A resident with a g-tube and cognitive impairment received medications via the g-tube without the LVN verifying tube placement using a stethoscope, as required by the care plan and facility policy. The DON confirmed that proper procedure was not followed, resulting in a deficiency related to medication administration practices.
A resident with a history of severe pressure injury and high risk factors was readmitted with an unhealed stage 4 sacral ulcer. Staff failed to perform a thorough skin check upon readmission and did not complete a required pressure injury reassessment within 24 hours. The initial wound evaluation misclassified the ulcer stage, and these assessment lapses led to a delay in identifying and treating the resident's pressure injury.
A resident with severe cognitive impairment and hemiplegia did not consistently receive physician-ordered passive ROM exercises and left knee splint application as required. Documentation showed that these restorative interventions were missed or not recorded on multiple occasions, despite facility policy and staff acknowledgment of their necessity to maintain mobility and prevent contractures.
A resident with multiple medical conditions and recent significant weight loss was not provided with a recommended Glucerna supplement due to the facility's failure to obtain a physician's order after readmission. Despite the IDT's care plan and ongoing monitoring by the RD and dietary consultant, the supplement was not administered for several days, contrary to facility policy and the resident's nutritional needs.
A resident with multiple medical conditions, including a history of blood clots, was prescribed Apixaban for DVT but was not adequately monitored for adverse effects such as bleeding. Although the care plan identified the risk and required monitoring, there was no documentation in the MAR or orders showing that nurses were assessing for bleeding while the resident was on anticoagulant therapy, contrary to facility policy and staff statements.
A resident with a history of depression, anxiety disorder, and schizophrenia, who was cognitively intact, and other residents reported that the survey results binder was kept behind a locked gate near the Administrator's Office, making it inaccessible without staff assistance. Observations and staff interviews confirmed that residents could not independently access the survey results, contrary to facility policy requiring survey reports to be readily accessible.
The facility did not complete and transmit MDS assessments within required timeframes for several residents with complex medical and psychiatric conditions. Both admission and quarterly assessments were delayed, as confirmed by the MDSC and DON, who acknowledged late completion and submission. This failure was identified through record reviews and staff interviews, and was not in accordance with federal guidelines and facility policy.
Two rooms were found to house five residents each, surpassing the regulatory limit of four residents per room. Staff interviews indicated no reported issues with providing care, even with several residents using wheelchairs and one requiring a lift. Facility policy stated a maximum of two residents per room, but this was not followed for the affected rooms.
Two rooms in the facility housed five residents each but did not meet the required 80 square feet per resident for multiple occupancy rooms, providing only 76.964 and 71.536 square feet per resident. Staff reported no issues with providing care, and the facility had requested a waiver, but the rooms did not comply with regulatory space requirements.
A resident with dementia and other health conditions was found with a scratch and bleeding under the eye after leaving another room. When a family member alleged the resident had been assaulted, the facility failed to report the abuse allegation to the State Survey Agency within the required two-hour window, instead delaying the report by approximately 72 hours.
A cognitively impaired resident with multiple medical conditions exited the facility unsupervised after a staff member opened a locked gate without verifying identity, due to the absence of a system for resident identification and monitoring of secure exits. The resident was not wearing an ID wristband, and staff did not have procedures in place to confirm whether individuals leaving were residents or visitors.
A resident with diabetes and other chronic conditions was not assessed for blood glucose upon returning to the facility after an unauthorized absence of about 24 hours. Despite being at risk due to missed diabetes medications, staff did not check blood sugar before providing a meal, contrary to facility policy and professional standards.
The facility operated without a licensed Administrator after the posted license expired and the renewal application was not submitted as required. The Administrator confirmed the lapse and acknowledged the failure to submit the renewal application in advance, contrary to facility policy and regulatory requirements.
Two residents' medical records were found to be incomplete due to missing physician signatures on an informed consent form and monthly Order Summaries. The informed consent for a medication was not signed by the physician, and the Order Summaries for another resident were not reviewed or signed by the attending physician as required. Facility staff confirmed these omissions during interviews, and facility policies require such documentation to be complete and accurate.
A resident with multiple health conditions did not receive prescribed medications due to a failure in following physician orders and documenting administration in the MAR. The facility's policy required timely administration and documentation, which was not adhered to, leading to a deficiency identified by surveyors.
A resident with cognitive impairments and no physician's order was found with unauthorized cold and flu medication at their bedside. The facility staff were unaware of the medication, which was brought by a family member. The facility's policy requires medications to be stored securely and only self-administered if deemed safe by the Interdisciplinary Team.
A facility failed to report an allegation of financial abuse involving a resident with severe cognitive impairment. The Director of Nursing was informed by a family member about another family member withdrawing large sums from the resident's account. The facility did not report the allegation to authorities, citing lack of proof and the incident occurring before admission. This failure to adhere to reporting policies placed the resident at risk for further abuse.
A resident with severe cognitive impairment and multiple diagnoses refused facility food and received outside food delivery, but the facility failed to create a comprehensive care plan addressing these dietary preferences. The DON acknowledged the oversight, which was contrary to the facility's policy requiring care plans for residents dissatisfied with their diet.
A facility failed to obtain the Attending Physician's signature on the informed consent for a resident's use of a Merry Walker, a device for assisting with mobility. The resident, who had cognitive impairments and was dependent on staff, required informed consent for the device's use. Despite reminders, the physician did not sign the consent form, contrary to facility policy requiring physician-signed consent before using such devices.
A resident with severe cognitive impairment and a history of disliking pasta was not provided meals that accommodated their preferences. Despite the facility's policy to assess and document food preferences upon admission, the resident's dislike for pasta was not reflected in their meal ticket, leading to a deficiency in care.
A kitchen staff member was observed not wearing a hair net while inside the kitchen, contrary to the facility's policy requiring hairnets for infection control. The staff member admitted forgetting to wear the hair net due to being busy. The DON confirmed the requirement for kitchen staff to wear hairnets at all times, as per the facility's policy, to prevent foodborne illnesses.
A facility failed to maintain accurate medical records for a resident with severe cognitive impairment who alleged financial abuse by a family member. Although the Social Service Director contacted the police, this action was not documented, violating the facility's policy for complete and accurate record-keeping.
The facility failed to maintain an effective infection prevention and control program, particularly concerning influenza, for two residents. Staff members, including an LVN and an AAC, did not follow proper PPE and hand hygiene protocols, risking the spread of infection. Additionally, housekeeping practices were inadequate, with used cleaning cloths placed on clean kitchen countertops. Other staff members, such as a housekeeper and the AMS, did not wear N95 masks properly, further compromising infection control measures.
A resident reported alleged financial abuse by a family member, but the facility failed to notify local law enforcement as required by its policy. Despite reporting to Adult Protective Services, the Ombudsman, and the California Department of Public Health, the facility did not contact the police, resulting in the allegation not being investigated by law enforcement.
A resident with severe cognitive impairment was subjected to physical abuse by a CNA, who hit the resident, causing a fall and a skin tear. Witnesses observed the CNA's inappropriate behavior, which was classified as physical abuse, violating the facility's policy on resident protection.
The facility failed to offer and document assistance with Advance Directives (ADs) for several residents, including one with intact cognition. Despite policy requirements, the facility did not ensure AD discussions were documented, potentially compromising residents' rights to have their healthcare wishes respected.
A facility failed to ensure a resident was free from physical restraints without proper assessment and authorization. The resident, with conditions including major depressive disorder and contracture, was observed with side rails up without a physician's order or informed consent. Staff confirmed the absence of necessary documentation, contrary to facility policy requiring a physician's order, assessment, and consent before applying restraints.
The facility failed to develop comprehensive care plans for residents with PTSD, diabetes, and those using physical restraints. A resident with PTSD did not have a care plan to address mental health needs, another resident receiving insulin lacked a care plan for diabetes management, and a resident using side rails as restraints did not have the necessary documentation or care plan. These deficiencies could lead to delays in necessary care and services.
Failure to Develop Person-Centered Care Plan for New Prednisone Therapy
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan for a resident’s new prednisone therapy. The resident was originally admitted with multiple diagnoses including muscle weakness, dysphagia, hypertensive heart disease with heart failure, and COPD. An MDS assessment documented moderate cognitive impairment and a need for partial to moderate assistance with toileting, bathing, and applying footwear. The physician issued a telephone order for prednisone 20 mg by mouth once daily for five days for cough, and this order was documented on the resident’s Order Summary Report. Despite the new prednisone order, licensed staff did not create a care plan addressing the resident’s prednisone use. During interview, the ADON stated that the purpose of a care plan is to create goals and address resident needs, and acknowledged that staff did not develop a care plan for this medication. The ADON explained that a care plan should have included goals and interventions such as monitoring vital signs and potential side effects, and directing staff to notify the physician if side effects occurred. Review of the facility’s policy on comprehensive person-centered care plans showed that care plans must include measurable objectives and timetables, be based on data gathering and clinical decision-making, address underlying problems, and be revised as resident conditions change. The absence of a care plan for the resident’s prednisone therapy was inconsistent with this policy.
Failure to Complete Timely Admission Assessment Upon Resident Re-Admission
Penalty
Summary
A deficiency occurred when nursing staff failed to complete a timely admission assessment for a resident who was re-admitted to the facility following a hospital stay. The resident, who had diagnoses including dementia, bipolar disorder, and schizoaffective disorder, was re-admitted in the afternoon. Despite facility policy requiring a head-to-toe assessment and documentation upon admission or re-admission, the assigned RN did not complete or document the required admission assessment at the time of the resident's return. Interviews revealed that the assigned RN checked on the resident's immediate well-being but did not perform or document a full admission assessment, instead endorsing the task to the treatment nurse and the next shift due to being occupied with another admission. The subsequent RN also did not complete the assessment, believing it was the responsibility of the prior shift, and further endorsed the task to the night nurse. As a result, the clinical admission assessment was not completed until the following early morning, several hours after the resident's re-admission. Facility policy and statements from the Director of Nursing confirmed that the admitting nurse is responsible for assessing and documenting the resident's condition upon arrival, with the option to endorse additional assessments to subsequent shifts. However, in this case, the required admission assessment was neither completed nor documented in a timely manner, contrary to professional standards and facility policy.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the State Survey Agency (SSA) after the Director of Staff Development (DSD) received a text message from a Certified Nurse Assistant (CNA) trainee stating she had witnessed abuse by another CNA. The trainee reported that residents were left soaking in urine for hours and that the CNA was rough and mean to many residents. The DSD attempted to obtain more information from the trainee, but the trainee was unresponsive and left the facility. The DSD informed the Administrator (ADMIN) of the allegations, but no further statement was obtained from the trainee. Despite being aware of the allegation, neither the DSD nor the ADMIN reported the incident to the SSA, and the accused CNA was not suspended pending investigation. The Director of Nurses (DON) confirmed that all allegations of abuse are to be reported to the ADMIN and that the facility must initiate an investigation and report the allegation within two hours. The facility's policy also required immediate reporting of suspected abuse, defined as within two hours. However, the facility did not report the allegation, citing the lack of a full statement from the trainee.
Failure to Check Required Parameters Before Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) prepared to administer Gabapentin to a resident without first checking the resident's respiration rate as required by the physician's order. The resident, who had diagnoses including dementia, neuralgia, and neuritis, was observed in a recliner wheelchair as the LVN prepared the medication by mixing Gabapentin with applesauce. The LVN was about to administer the medication when a surveyor intervened and asked the LVN to stop. Upon review, the Medication Administration Record (MAR) indicated that Gabapentin should be held if the resident's respiration rate was less than 12, and the physician should be notified. The LVN admitted that the respiration rate had not been checked immediately prior to administration, as required, but claimed it had been checked 15 minutes earlier without documentation. The Director of Nursing (DON) confirmed that checking parameters such as respiration rate is a required part of the physician's order and that failure to do so constitutes a significant medication error. Facility policy defined a medication error as the preparation or administration of drugs not in accordance with the physician's order. The policy also stated that staff should strive to minimize adverse consequences resulting from medication errors. The incident was identified through observation, interview, and record review, and it was determined that the failure to check the resident's respiration rate immediately before administering Gabapentin was a significant medication error.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices related to the handling and documentation of resident medical records. The report notes that the required standards for protecting confidential information and maintaining accurate, complete records were not met.
Failure to Perform Hand Hygiene Prior to Medication Preparation
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) prepared to administer Gabapentin to a resident without first performing hand hygiene, as required by the facility's infection prevention and control protocol. The LVN entered the resident's room, prepared the medication by unscrewing two Gabapentin capsules to mix with applesauce, but did not wash hands or use alcohol-based hand sanitizer prior to handling the medication. The LVN acknowledged during an interview that handwashing had only occurred earlier, downstairs, and that he had touched doorknobs while using the stairs to return to the resident's room before preparing the medication. The resident involved had diagnoses including dementia, neuralgia, and neuritis, with functional limitations in the lower extremities and limited ability to make concrete requests, though able to comprehend most conversation. The facility's policy, reviewed and dated July 2024, specifies that all personnel must perform hand hygiene before preparing or handling medications. The Director of Nursing confirmed that handwashing is required before medication preparation and handling, and failure to do so could result in the spread of infection.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to assist a resident with their meal in a manner that promoted dignity and quality of life. The resident, who had diagnoses including dementia, anxiety disorder, and lack of coordination, was dependent on staff for various activities of daily living and required supervision with eating. During an observation, the CNA was seen standing over the resident while assisting with the meal, rather than sitting at eye level as required. The CNA acknowledged that a chair was available but was not used, and stated that they did not sit because the resident might try to get up. The CNA also recognized that the proper procedure was to sit at eye level with the resident during meal assistance. The Director of Nursing (DON) confirmed in an interview that staff are expected to sit at eye level with residents when assisting with meals, and that standing over a resident does not respect the resident's right to dignity. A review of the facility's policy and procedures on meal assistance further indicated that residents should be assisted in a manner that ensures safety, comfort, and dignity, specifically stating that staff should not stand over residents while assisting them with meals. This failure to follow policy and procedure resulted in the resident not being treated with dignity during meal assistance.
Failure to Develop and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in deficiencies related to the delivery of necessary care and services. For one resident with cerebrovascular disease, major depressive disorder, and vascular dementia, the facility did not implement the care plan for a wheelchair pad alarm as ordered by the physician, and failed to develop a care plan addressing the resident's behavior of removing the bed pad alarm. Observations confirmed the resident was without the required wheelchair pad alarm on multiple occasions, and staff interviews acknowledged the absence of a care plan for the resident's removal of the bed alarm, despite documented falls and incidents related to this behavior. Additionally, the same resident was prescribed Ativan and Haldol for anxiety and related symptoms, but there was no care plan developed for the use of these medications. Staff interviews and record reviews confirmed the lack of a care plan to monitor the administration and effects of these medications, contrary to facility policy requiring measurable objectives and timeframes for all care interventions, including medication management. For another resident with Alzheimer's disease and a history of falls, the facility did not develop or implement a comprehensive care plan for the use of a restraint pad/tab alarm, despite the resident being at high risk for falls and the device being in use. Similarly, a third resident with chronic osteomyelitis, diabetes, and MRSA infection was prescribed an antibiotic (Cephalexin), but no care plan was developed or implemented to monitor the effectiveness or adverse effects of the medication. Staff interviews confirmed the absence of care plans for these interventions, and facility policies require comprehensive care plans for all such treatments and devices.
Failure to Follow Physician Orders and Professional Standards in Resident Care
Penalty
Summary
Nursing staff failed to follow physician orders and facility policies in the care of two residents. For one resident with a history of cerebrovascular disease, major depressive disorder, and vascular dementia, nurses did not monitor and document blood pressure in the lying position as ordered for orthostatic hypotension assessment on three consecutive Tuesdays. The Assistant Director of Nursing confirmed that the required blood pressure checks were not performed or documented, and the Director of Nursing acknowledged that this failure prevented identification and management of orthostatic hypotension. Additionally, after the same resident experienced a fall, neurochecks were not completed or documented at seven required intervals within a 72-hour period post-fall. Interviews with nursing staff revealed that neurochecks were missed due to distractions and failure to follow post-fall protocols. The Director of Nursing confirmed that the facility's policy required neurological assessments after falls, and that these were not performed as expected, which could have delayed identification of changes in the resident's condition. For another resident with diabetes mellitus, cerebral vascular accident, and major depressive disorder, nurses failed to rotate insulin injection sites as ordered and per facility policy on multiple occasions. Both the Licensed Vocational Nurse and the Director of Nursing confirmed that insulin injections were repeatedly administered at the same site by different nurses, contrary to physician orders and manufacturer guidelines. This practice was acknowledged as inconsistent with professional standards and facility policy, which require rotation of injection sites to prevent complications.
Failure to Prevent Accident Hazards and Ensure Resident Supervision
Penalty
Summary
Multiple deficiencies were identified in the facility related to accident hazards and inadequate supervision of residents. One resident with a history of cerebrovascular disease, major depressive disorder, and vascular dementia was admitted with orders and care plans specifying the use of a wheelchair pad alarm to alert staff when the resident attempted to get up unassisted. Despite these orders, the resident was observed on multiple occasions without the required wheelchair pad alarm, and had experienced falls, including one incident where the resident removed the bed pad alarm. Interviews with nursing staff and review of facility policy confirmed that the alarm was not in place as required, increasing the risk of falls and injury. Another resident with severe cognitive impairment and a history of falls was found to have a fall mat in place as ordered, but the bed wheel was positioned on top of the mat. This placement was confirmed by staff to potentially cause permanent indentations, reducing the mat's effectiveness in cushioning falls. Facility instructions and policy explicitly state that heavy objects should not be left on fall mats to prevent damage and maintain their protective function. A third resident, also at high risk for falls, was observed with a broken pad/tab alarm sensor cord, rendering the alarm nonfunctional. There was confusion among staff regarding responsibility for ensuring the alarms were operational, with nursing, maintenance, and central supply staff each providing different accounts. Facility policy and equipment manuals require daily testing and proper connection of alarms to ensure resident safety. Additionally, a resident was found with an individual packet of A&D ointment at the bedside, despite not being assessed as safe for self-administration of medication. Staff interviews and facility policy confirmed that such medications should not be left accessible to residents, as this poses a safety risk.
Failure to Administer and Document Medications per Policy
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to administer and document medications according to facility policy and physician orders for a resident with multiple complex medical conditions, including sepsis, acute respiratory failure, schizoaffective disorder, seizure disorder, dementia, and hypertensive chronic kidney disease. The resident had specific medication orders for divalproex sodium, apixaban, olanzapine, and metoprolol succinate, with scheduled administration times. The LVN administered divalproex sodium, apixaban, and olanzapine at 7:30 a.m., which was earlier than the scheduled 9 a.m. time, and outside the facility's policy of administering medications within one hour of the scheduled time unless otherwise specified. The LVN did not document the early administration of these medications at the time they were given. Instead, documentation was completed later in the medication administration record (MAR), and the administration was recorded as occurring at the scheduled 9 a.m. time, rather than the actual time of 7:30 a.m. This was confirmed through interviews and record reviews with facility staff, including the infection preventionist, registered nurse, and director of nursing, all of whom stated that the facility policy requires medications to be administered and documented within one hour of the scheduled time and immediately after administration. The LVN stated that the decision to administer all morning medications together at 7:30 a.m. was based on personal preference and the resident's unpredictable willingness to take medications at different times, rather than following physician orders or facility policy. The facility's policy also requires that any changes to medication administration times be approved by the physician, and that all medication administration be documented immediately after giving the medication. The failure to follow these procedures resulted in a deficiency related to pharmaceutical services, specifically in the accurate administration and documentation of medications.
Medication Error Rate Exceeds Acceptable Threshold Due to Early Administration and Documentation Failures
Penalty
Summary
The facility failed to ensure that its medication error rate remained below five percent, as required. During a medication pass observation, a nurse administered three medications—divalproex sodium, apixaban, and olanzapine—to a resident at 7:30 a.m., which was earlier than the scheduled administration time of 9 a.m. This early administration was not within the facility's policy of administering medications within one hour of the prescribed time, and there was no documentation to justify the deviation or to indicate that the medications were given early. The nurse later documented the medications as being given at the scheduled time, rather than at the actual time of administration. The resident involved had a complex medical history, including sepsis, acute respiratory failure with hypoxia, paranoid schizoaffective disorder, seizure disorder, dementia, and hypertensive chronic kidney disease. The resident required varying levels of assistance for daily activities and had specific medication orders for the management of mood disorders and stroke prophylaxis. The nurse stated a preference to administer all morning medications at the same time for the resident's convenience, but did not follow the required process of contacting the physician to adjust medication times or documenting the early administration. Interviews with facility staff, including the Infection Preventionist, RN, and DON, confirmed that the facility's policy mandates medication administration within one hour of the scheduled time unless otherwise specified, and that any deviations must be documented with a reason. The nurse did not adhere to these policies, resulting in three medication errors out of 25 opportunities, leading to a medication error rate of 12%. This failure was directly attributed to the nurse's actions and lack of proper documentation, as well as not following established protocols for medication administration and resident care preferences.
Failure to Rotate Insulin Injection Sites Results in Significant Medication Error
Penalty
Summary
The facility failed to rotate insulin injection sites as required when administering insulin to one resident with diabetes mellitus, cerebral vascular accident, hypertension, and major depressive disorder. Multiple nurses administered insulin injections to the same site repeatedly over several dates, as confirmed by review of the resident's Location of Administration Report for two consecutive months. Both the LVN and DON acknowledged that the facility did not follow the physician's orders, professional standards, or manufacturer specifications, all of which require rotation of injection sites to ensure proper absorption of insulin. The resident in question was dependent on staff for mobility and activities of daily living and had difficulty communicating. Facility policy and procedure documents reviewed indicated that injection sites should be rotated and defined a medication error as any administration not in accordance with physician orders or accepted standards. The DON confirmed that the repeated failure to rotate injection sites by multiple nurses constituted a significant medication error, as it did not comply with the prescribed method of insulin administration.
Deficient Food Storage, Labeling, and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen. During an initial kitchen tour, multiple food items in Refrigerator 1, the Walk-in Refrigerator, and the Walk-in Freezer were found to be unlabeled or mislabeled, contrary to facility policy. Items such as a clear plastic pitcher of white liquid, an opened container of yogurt, an opened container of creamer, an unlabeled pan of thick sauce, and a container of cut-up lettuce and shredded carrots labeled as jelly were all improperly labeled or not labeled at all. Staff interviews confirmed that labeling is required to identify food contents and preparation dates, especially for residents with allergies or special dietary needs, but this process was not followed. The facility's policy and USDA guidelines require all food items to be labeled with contents and dates to prevent serving expired or unsafe food. Additionally, the kitchen areas were not maintained in a clean and sanitary condition. The Walk-in Freezer had sticky, dirty ice buildup on the floor at the entrance, which was observed on multiple days and acknowledged by dietary staff as a safety and sanitation issue. The Dry Food Storage Area had spilled dry cereal on top of canned food and plastic bins, which was not cleaned up promptly, even after being identified by staff. Facility policies require daily cleaning of all kitchen areas and immediate cleanup of spills to prevent pest attraction and cross-contamination, but these procedures were not followed. Furthermore, the facility failed to properly separate and remove dented cans from the Dry Food Storage Area. Despite having a designated bin for dented cans, surveyors found five dented cans (including mandarin oranges, sliced apples, and Chile Verde sauce) stored with non-dented cans on the shelves. Staff interviews and facility policy confirmed that food from dented cans should not be served due to the risk of bacterial contamination, and dented cans are to be removed and returned to the distributor. The presence of dented cans on the shelves indicated that the facility's procedures for inspecting and segregating damaged goods were not consistently implemented.
Deficiencies in Clinical Record Accuracy and Documentation
Penalty
Summary
Surveyors identified multiple deficiencies related to the maintenance of accurate and complete clinical records for several residents. For one resident, there was conflicting documentation regarding the presence of an Advance Directive. The admission record and Advance Healthcare Directive Acknowledgment indicated the resident did not have an Advance Directive, while the Psycho-Social Assessment stated otherwise. This inconsistency was confirmed by the Social Service Director, who acknowledged the documentation was inaccurate and could cause confusion regarding the resident's care preferences. Another deficiency involved the administration and documentation of medications. An LVN administered several medications to a resident earlier than the scheduled time and failed to document the actual time of administration in the Medication Administration Record (MAR). Instead, the LVN later recorded the medications as being given at the scheduled time, which was not accurate. Interviews with nursing staff and review of facility policies confirmed that medications should be administered and documented at the correct times, and any deviations should be clearly recorded. The inaccurate documentation in the MAR had the potential to mislead staff about the resident's medication administration throughout the day. Additional findings included incomplete informed consent documentation for psychotropic medications for two residents. In one case, informed consent forms for medications were not signed and dated by the physician, and in another, the physician's signature was undated and the verification method by the nurse was not completed. Facility policy required that informed consent forms be fully completed, including signatures, dates, and verification details. The lack of complete documentation for informed consent and medication administration was confirmed by nursing leadership and was not in accordance with the facility's own policies and accepted professional standards.
Infection Control Deficiencies in Medication Administration and Linen Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple observed deficiencies. During a medication administration observation, an LVN did not disinfect a metal tray used to transport medications between two residents. The tray was placed on surfaces in both residents' rooms and on the medication cart without being cleaned between uses. The LVN acknowledged that the tray should have been disinfected between residents to prevent disease transmission but stated that it was forgotten due to nervousness. Facility policy required all equipment to be cleaned with disinfectant wipes before and after use on residents, and the DON confirmed that the policy was not followed in this instance. Additionally, the facility did not ensure that mobile linen carts were covered with non-permeable material. Observations revealed that several linen carts were covered with permeable mesh material, both in resident care areas and in the laundry department. Staff, including the Infection Preventionist, District Manager, and Account Manager, acknowledged that the covers should be non-permeable to prevent environmental contaminants from settling on clean linens. The Administrator explained that there was a mistake in the ordering process for new covers, resulting in the continued use of inappropriate mesh covers. A further deficiency was observed in the laundry room, where a staff member's personal water container was found inside a linen cart next to clean linens. Both the Account Manager and Infection Preventionist confirmed that food and drink are not permitted in the clean laundry room to prevent contamination of linens. Facility policies reviewed indicated that maintaining a safe, sanitary environment and preventing cross-contamination are primary responsibilities for all staff. These observed practices were inconsistent with the facility's infection control policies and had the potential to contribute to the spread of communicable diseases and infections among staff and residents.
Failure to Monitor Residents for Adverse Effects During Antibiotic Therapy
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not ensuring that residents receiving antibiotics were properly monitored for adverse effects and effectiveness of the medication. For one resident with metabolic encephalopathy, sepsis due to MRSA, and dementia, there was no documented evidence that monitoring was performed during the administration of vancomycin, despite physician orders and care plans indicating the need for such monitoring. The Infection Preventionist confirmed that no monitoring was documented on specific dates, and the Director of Nursing acknowledged the failure to monitor for possible side effects. Another resident with chronic osteomyelitis, diabetes, and MRSA infection was prescribed cephalexin for a bilateral foot infection. The order summary did not include instructions to monitor for adverse effects, and there was no care plan addressing the use of cephalexin. The Infection Preventionist and Director of Nursing both stated that monitoring for adverse effects was not performed, and the facility's policy required such monitoring as part of its antibiotic stewardship program. A third resident with cerebrovascular disease, major depressive disorder, and vascular dementia was prescribed cephalexin and later Bactrim for a urinary tract infection. Although care plans were in place to assess for adverse reactions, there was no documented evidence of monitoring for adverse effects on multiple days during the course of antibiotic therapy. The Infection Preventionist confirmed the lack of documentation and emphasized the importance of monitoring to determine the effectiveness of the antibiotics and to prevent complications.
Failure to Maintain Safe Electrical Equipment for Residents
Penalty
Summary
The facility failed to maintain electrical patient care equipment in safe operating condition for three residents. For one resident with Alzheimer's disease, osteoporosis, and a history of falls, a pad/tab alarm intended to alert staff when the resident attempted to get out of bed was found with a broken sensor cord, rendering the alarm nonfunctional. The resident was assessed as high risk for falls and required substantial assistance with mobility and activities of daily living. Staff confirmed that the broken cord meant the alarm would not sound, and the device was not checked for functionality as required. Two other residents, both with severe cognitive impairments and high fall risk, were found to have bed remote controls with frayed or exposed wires. Staff observed the damaged wires and acknowledged that such conditions should not exist near residents. Maintenance staff and the DON confirmed that it was their responsibility to ensure beds and related equipment were safe and that all staff were expected to report any broken equipment to the Maintenance Department. Facility policies reviewed indicated a commitment to maintaining a safe environment, including bed and electrical safety, through ongoing employee training, monitoring, and reporting processes. Despite these policies, the observations and interviews revealed that the required checks and reporting of unsafe equipment were not consistently performed, resulting in the presence of hazardous equipment in resident rooms.
Failure to Follow Protocols for Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that three residents were free from the use of physical restraints without proper procedures, including obtaining a physician's order, informed consent, and conducting a restraint assessment. For one resident with a history of falls, impaired cognition, and limited mobility, the bed was placed against the wall, restricting bed exit and entry to one side. There was no physician's order, informed consent from the resident or representative, restraint assessment, or care plan for this intervention, despite the resident's inability to make decisions and high risk for falls. Two other residents, both with significant cognitive impairment and high fall risk, had pad/tab alarms applied to their beds. These alarms, considered restraints by facility staff and policy, were used to alert staff when the residents attempted to get out of bed. In both cases, there was no physician's order, no informed consent, no restraint assessment, and no care plan developed prior to the application of the alarms. Staff interviews confirmed that these steps were not taken and acknowledged the alarms' restrictive nature. The facility's own policy requires a physician's order, informed consent, and a restraint assessment before applying any restraint, as well as the development of a care plan addressing the use and reduction of restraints. Despite these requirements, the necessary documentation and assessments were not completed for the residents in question, resulting in the use of restraints without adherence to established protocols.
Failure to Keep Call Light Within Reach for High-Risk Resident
Penalty
Summary
The facility failed to ensure that the call light was kept within reach for a resident who was at high risk for falls and required substantial assistance with mobility and activities of daily living. The resident had a history of muscle weakness, abnormal gait, impaired vision, moderate cognitive impairment, and was assessed as high risk for falls. The care plan specifically included an intervention to keep the call light within easy reach and encourage its use for assistance. During an observation, the call light was found on the floor, out of the resident's reach, and staff confirmed that it should have been accessible at all times. Interviews with facility staff, including the Infection Preventionist and the DON, confirmed that ensuring the call light is within reach is a staff responsibility and is especially important for residents with cognitive or physical impairments. The facility's policy also required that each resident be provided with a means to call staff for assistance from their bed and other areas.
Failure to Conduct Required Quarterly IDT Review for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a quarterly behavior management interdisciplinary team (IDT) meeting was conducted for a resident who was prescribed psychotropic medications, specifically sertraline and mirtazapine, for depression and related symptoms. The resident, who had diagnoses including cerebrovascular disease, major depressive disorder, and vascular dementia, was admitted with moderate cognitive impairment and was receiving antidepressant therapy as documented in the medical record. Despite facility policy requiring quarterly IDT reviews for residents on psychotropic medications, the last documented behavioral IDT for this resident occurred at the time of admission, with no subsequent quarterly reviews completed. Interviews with facility staff, including the Assistant Director of Nursing (ADON), a Registered Nurse (RN), the Administrator, and the Director of Nursing (DON), confirmed that the required quarterly behavioral IDT reviews were not performed. Staff acknowledged that the IDT process is essential for evaluating the continued need for psychotropic medications, discussing the resident's behavior with the physician, and determining whether medication adjustments or discontinuation are appropriate. The absence of these reviews meant that the resident's behavior and medication regimen were not reassessed as required by facility policy. A review of the facility's policies and procedures further supported the requirement for regular, at least quarterly, IDT reviews for residents on psychotropic medications to ensure appropriateness and minimize adverse consequences. The failure to conduct these reviews was acknowledged by the DON, who stated that the resident could potentially be taking unnecessary medication due to the lack of ongoing assessment and follow-up with the physician.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within the required timeframe, as mandated by federal and state law. Specifically, a resident with dementia, carcinoma, and agitation was found on the floor outside the bathroom, in pain and alleging that another resident had pushed them. The incident resulted in a significant injury—a comminuted, mildly displaced, impacted intertrochanteric fracture of the right hip—requiring transfer to an acute care hospital. The resident's medical records indicated cognitive impairment and a need for staff assistance with daily activities. Despite the resident's clear allegation of being pushed, the staff members present at the time, including an LVN and an RN, did not report the abuse allegation to the Director of Nursing (DON) or the Administrator (ADM) as required by facility policy. The LVN assumed the RN would report the incident, but neither followed up or ensured the allegation was communicated to the appropriate authorities. The DON and ADM only became aware of the abuse allegation the following day, after the injury had already been reported to the state agency as a fall, but not as a potential abuse incident. Upon learning of the abuse allegation, neither the DON nor the ADM reported it to the California Department of Public Health, the ombudsman, or local law enforcement within the required two-hour window. Both acknowledged during interviews that the facility's policy and procedure for reporting abuse was not followed. The failure to report the allegation immediately resulted in a delay in investigation and notification to the proper authorities, as required by both facility policy and regulatory requirements.
Failure to Verify G-Tube Placement Prior to Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to verify the placement of a resident's gastrostomy tube (g-tube) prior to administering medications. The resident, who had diagnoses including Alzheimer's disease, dementia, and required attention to a gastrostomy, was unable to make decisions and had limited ability to communicate. The resident's care plan specifically included interventions to check and maintain the placement and patency of the g-tube. During medication administration, the LVN prepared and administered medications via the g-tube but did not use a stethoscope to confirm tube placement, as required by both facility policy and the resident's care plan. The LVN acknowledged during an interview that the standard procedure was to use a stethoscope to listen for proper g-tube placement before administering medications, but this step was omitted. The Director of Nursing confirmed that the facility's process required verification of g-tube placement to ensure safe medication administration. Facility policy also outlined the need to verify tube placement prior to administering medications through an enteral tube. This failure to follow professional standards of practice and facility policy constituted a deficiency in care for the resident.
Failure to Perform Timely Skin Assessment and Pressure Injury Reassessment
Penalty
Summary
A resident with a history of pressure-induced deep tissue damage, mild protein-calorie malnutrition, and adult failure to thrive was readmitted to the facility with an unhealed stage 4 pressure injury on the sacrum. Upon readmission, the resident was dependent on staff for mobility and activities of daily living, was incontinent of urine and stool, and was identified as high risk for pressure injury. The care plan included skin and ulcer treatment, use of a pressure-reducing device, turning and repositioning, and nutrition and hydration interventions. Despite these risk factors and care needs, a thorough skin check was not performed upon the resident's readmission. The admitting RN did not complete a comprehensive skin assessment, citing the resident's refusal to turn, and failed to document the refusal or communicate the need for follow-up to the next shift. Additionally, the treatment nurse did not perform a pressure injury reassessment within 24 hours of readmission, as required by facility policy. The initial wound evaluation after readmission incorrectly documented the pressure injury as stage 3 instead of stage 4, which was only corrected several days later by another nurse. These lapses in assessment and documentation resulted in a delay in identifying and appropriately classifying the resident's pressure injury. The facility's own policies required comprehensive skin assessments upon admission and a reassessment by a treatment nurse within 24 hours, but these were not followed. Interviews with nursing staff and the DON confirmed that the required assessments were not completed in a timely manner, and that the failure to assess and document the resident's skin condition led to a delay in necessary care and treatment.
Failure to Provide Ordered Restorative Nursing Care and ROM Interventions
Penalty
Summary
The facility failed to provide appropriate restorative nursing care for a resident with limited range of motion (ROM) and physician's orders for passive ROM exercises and use of a left knee splint. The resident, who was admitted with diagnoses including dementia, generalized muscle weakness, and hemiplegia affecting the left side, was dependent on staff for all activities of daily living and had severely impaired cognitive skills. Physician orders and the care plan specified that passive ROM exercises and application of a left knee splint were to be performed five times a week. Record review and staff interviews revealed that, during a specified week, the resident received passive ROM exercises only three times and had the left knee splint applied four times, rather than the ordered five times per week. Documentation was incomplete, and staff acknowledged that the required services were either not performed or not documented as performed. The Restorative Nursing Assistant (RNA) and Director of Rehabilitation confirmed that the resident should have received these interventions five times weekly, as per physician orders. Observations showed the resident had a contracted left leg, and staff interviews indicated that the lack of consistent passive ROM and splint use could contribute to further decline in physical function. Facility policy required accurate documentation and adherence to prescribed restorative programs, but this was not followed for the resident in question during the reviewed period.
Failure to Provide Therapeutic Diet as Recommended by IDT
Penalty
Summary
A deficiency occurred when the facility failed to provide a therapeutic diet as recommended by the Interdisciplinary Team (IDT) for a resident with a history of dysphagia, major depressive disorder, and gastro-esophageal reflux disease. The resident experienced significant weight loss over several months, as documented in the Weights and Vitals Summary, and was identified as high risk for excessive weight loss by the Registered Dietician. The IDT Weight Management Care Plan recommended the addition of a Glucerna shake once daily for one month to address the resident's nutritional needs. Despite this recommendation, the Assistant Director of Nursing (ADON) did not obtain a physician's order to resume the Glucerna supplement after the resident's readmission, resulting in the resident not receiving the supplement for five days. The Medication Administration Record still reflected a previous order, but the supplement was not administered due to the lack of a current physician's order. Both the ADON and the Director of Nursing (DON) acknowledged that the IDT's recommendation was not followed, and the Dietary Consultant confirmed that licensed nurses should have obtained the necessary order to prevent further weight loss. The facility's policy on Weight Assessment and Intervention requires interventions for undesirable weight loss to be based on the resident's nutrition and hydration needs. In this case, the failure to implement the IDT's recommendation and obtain a physician's order for the Glucerna supplement resulted in a lapse in care for a resident at high risk for continued weight loss.
Failure to Monitor for Adverse Effects of Anticoagulant Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral vascular accident, diabetes mellitus, hypertension, major depressive disorder, deep vein thrombosis, and pulmonary embolism was prescribed Apixaban, an anticoagulant, for deep vein thrombosis of the lower extremity. The resident's care plan identified a risk for bleeding and bruising due to anticoagulant therapy, and it directed nurses to assess for signs and symptoms of bleeding. However, review of the resident's Medication Administration Record (MAR) and Order Summary Report revealed there was no documented order or evidence that nurses were monitoring for adverse effects, such as bleeding, while the resident was on anticoagulant therapy. Interviews with nursing staff and the Director of Nursing confirmed that monitoring for adverse effects, particularly bleeding, is required for residents on anticoagulant medications. The facility's policy also stated that residents receiving medications with potential adverse consequences must be monitored to ensure prompt identification and reporting of such effects. Despite this, there was no documentation in the MAR indicating that monitoring for bleeding was being performed for this resident while on Apixaban.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to ensure that the results of the most recent survey were posted in a location that was readily accessible to residents without requiring staff assistance. During interviews and observations, it was found that the survey binder containing the survey results was kept on the opposite side of a locked gate near the Administrator's Office. Residents, including the Resident Council President, confirmed that they knew where the binder was kept but could not access it independently. The binder was not present in the designated holder during observation, and staff confirmed that residents would need to ask for assistance to view the survey results. A review of facility policy indicated that survey reports and plans of correction should be readily accessible to residents, family members, and the public, and that a copy should be kept in the residents' day room. However, the current practice did not align with this policy, as the binder was not accessible to residents without staff intervention. The deficiency was identified during a review of a resident with a history of depression, anxiety disorder, and schizophrenia, who was cognitively intact according to the most recent assessment.
Failure to Complete and Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to complete and transmit the Minimum Data Set (MDS) assessments within the required timeframes for six sampled residents. These residents had various diagnoses, including schizophrenia, hypokalemia, tachycardia, dementia, generalized anxiety disorder, encephalopathy, Parkinson's disease, schizoaffective disorder, major depressive disorder, migraine, and generalized muscle weakness. Record reviews showed that both admission and quarterly MDS assessments were not completed or submitted on time for each of these residents, with some assessments being completed or transmitted several days or even months after the required deadlines. Interviews with the MDS Coordinator (MDSC) confirmed that the MDS assessments for the identified residents were not exported or submitted in a timely manner. The MDSC acknowledged that assessments were completed late and, in some cases, not uploaded to the third-party system used for submission. The MDSC also explained the importance of timely MDS completion and transmission, noting that delays could result in inaccurate resident assessments and care planning. The Director of Nursing (DON) also confirmed that the facility did not adhere to Medicare guidelines for MDS assessment completion and transmission. The DON stated that the MDSC is responsible for ensuring timely completion and submission of MDS assessments and emphasized the importance of following federal regulations to ensure accurate care planning and reporting. Review of the facility's policy and the CMS Resident Assessment Instrument Manual confirmed the required timeframes for MDS completion and transmission, which were not met in these cases.
Exceeding Maximum Resident Occupancy in Shared Rooms
Penalty
Summary
The facility failed to comply with federal requirements limiting the number of residents per room, as two rooms were found to house five residents each, exceeding the maximum of four residents per room. This was identified through observation, interviews, and record review, including the facility's Census List and Client Accommodation Analysis Form, which confirmed the presence of five residents in each of the two rooms. The rooms in question provided between 71.536 and 76.964 square feet per resident. The facility had submitted a waiver request, stating that the rooms had no obstructions and sufficient space for care, dignity, and privacy, but the actual occupancy exceeded regulatory limits. Interviews with staff, including a CNA and an LVN, indicated that they did not experience issues providing care in these rooms, even with multiple residents using wheelchairs and one resident requiring a lift machine. The facility's policy and procedure, last reviewed in July 2024, stated that bedrooms should accommodate no more than two residents at a time, which was not followed in these instances. All ten sampled residents in the affected rooms were impacted by this deficiency.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that two resident rooms met the required minimum square footage per resident, as specified by federal and state regulations. Specifically, two rooms each housed five residents, but the available space per resident was below the mandated 80 square feet for multiple occupancy rooms. One room provided 76.964 square feet per resident, while the other provided only 71.536 square feet per resident. This was confirmed through review of the facility's census list, accommodation analysis, and a waiver request letter, which acknowledged the shortfall in space but asserted that care, dignity, and privacy were maintained. Interviews with facility staff, including a CNA and an LVN, indicated that they did not experience issues providing care in these rooms, even with residents who were ambulatory, used wheelchairs, or required lift assistance. The facility's policy and procedure document also reiterated the square footage requirements and noted that variations may be permitted if resident health and safety are not adversely affected. However, the rooms in question did not meet the standard square footage per resident as required.
Failure to Timely Report Alleged Resident Abuse
Penalty
Summary
The facility failed to follow its policy and procedure regarding the timely reporting of suspected abuse. Specifically, after a family member alleged that a resident had been assaulted, the facility did not report this allegation to the State Survey Agency (SSA) within the required two-hour timeframe. The incident was reported to the SSA approximately 72 hours after the allegation was made, rather than immediately as required by facility policy and regulatory guidelines. Interviews with the administrator confirmed the delay and acknowledged that the report was not made until several days after the initial allegation. The resident involved had a history of dementia, muscle weakness, and major depressive disorder, and required varying levels of assistance with daily activities. The resident was found with a scratch and mild bleeding under the left eye after being observed leaving another room. The family member raised concerns about possible abuse, prompting the requirement for immediate reporting. Despite this, the facility did not notify the appropriate authorities, including the SSA, within the mandated timeframe, resulting in a deficiency related to the timely reporting of suspected abuse.
Failure to Supervise and Identify Resident Leads to Unsupervised Exit
Penalty
Summary
A cognitively impaired resident, recently admitted to a secured facility, was able to exit the building unsupervised after a restorative nurse aide (RNA) opened a locked gate without verifying the individual's identity. The RNA mistakenly believed the resident was a visitor and did not check for an identification wristband or confirm with licensed nursing staff before allowing the person to leave. Video surveillance confirmed that the resident walked through the locked gate and exited the facility without staff present in the lobby. The resident had a history of dementia, psychosis, and was considered gravely disabled, with multiple medical diagnoses including hypertension, diabetes, and a history of self-neglect. Upon admission, the resident required assistance with activities of daily living and was not provided with an identification wristband, as the facility did not utilize them at the time. Staff interviews revealed that there was no policy or procedure in place for verifying the identity of individuals leaving through the locked gate, nor was there a system for monitoring the gate or ensuring residents wore identification wristbands. The incident was discovered when staff were unable to locate the resident, prompting a search and notification of local authorities. The facility's policies on wandering, elopement, and supervision referenced general safety measures but did not address specific procedures for resident identification or monitoring of secure exits. Staff involved acknowledged that the failure to verify identity and lack of a monitoring system contributed directly to the resident's unsupervised exit from the facility.
Plan Of Correction
Immediate Corrective Action: On 04/24/2025, the facility, under Administrator and Director of Nurses instruction, initiated the missing resident protocol. The staff called local hospitals. The facility searched facility premises and close surroundings. Local Law enforcement was called for support. MD was informed. Resident's representative was informed. The facility continued search on 04/25/2025. On 4/25/2025 at around 5:00 pm, Resident 1 was located and found in her apartment approximately 7.8 miles away from the facility, by RN 1 and LVN 1 and 2, with support from local police officers. On 4/25/2025 at around 5:56 pm, Resident 1 returned to the facility accompanied by RN 1, LVN 1 and 2, and local police officers. Resident 1's vital signs were checked by RN 2: B/P - 154/52, Temperature - 98.5, Respiration - 17, Pulse - 73 (regular), and oxygen saturation was 96% on room air. Resident 1 was alert and oriented x2. Resident denied pain and no emotional distress was noted. Resident 1's skin condition was also checked upon return by RN 2 and noted to have a scab on LT knee and discoloration on LT gluteal area, which were already identified on admission on 4/25/2025. Resident 1 ate at around 6:50 pm and consumed 100% of her meals. On 4/25/2025, Resident 1's attending physician was notified of her return at around 6:00 pm, and the known emergency contact was also notified and aware of her return at around 6:00 pm. On 4/25/2025 at around 8:30 pm, Resident 1 was transferred to a general acute care hospital (GACH) for further evaluation. On 4/26/2025, Resident 1's blood sugar level was 186, taken at the GACH at around 11:50 pm. On 4/25/2025, RNA 1 was given a disciplinary action and was suspended by the Administrator until further notice pending investigation. This resulted in immediate termination on 04/25/2025. From 6:30 am on 4/25/2025 to 4/26/2025, the Director of Nursing, QA Nurse Consultant, and Director of Staff Development conducted a series of in-service training and re-education to staff about Safety and Supervision of Resident policy, Elopement, Missing Person, and Resident Identification policies, with emphasis on the following: - The purpose and importance of identifying and confirming with Licensed Nurse/RN Supervisor/DON or Administrator/Receptionist whether the person leaving is a visitor and not a Resident of the facility first and foremost before allowing anyone to leave the premises for safety. - The purpose and importance of keeping Residents safe and well-being, particularly in a secured setting, by supervising Residents while in the facility as needed and being mindful of their whereabouts at all times to ensure their safety. - The purpose and importance of identifying Residents by checking if they are wearing an ID wristband or have another form of identification (e.g., photographs) to help identify Residents and ensure they receive appropriate care and services. - The purpose and importance of immediate action/interventions, such as initiating a code (GREEN) to start a search immediately once a Resident is found missing. - The purpose and importance of seeking assistance from Local Police on a search. As of 4/25/2025, there are 113 employees who have received in-service training and re-education, and on 4/26/2025, an additional 10 employees received training, totaling 95% of current employees who have completed their required in-services/re-education regarding the topics mentioned above, excluding 7 employees currently on leave of absence (LOA)/vacation. This training and re-education are ongoing and will continue until all 130 active staff/employees are captured. On 05/14/2025 through 5/15/2025, re-education and training were conducted by a Licensed Psychologist. The facility has 130 current employees, of which 123 completed their required in-services, re-education, and post-test, reaching a total of 95%. Out of the 130 employees, 7 are excluded due to LOA/vacation. This training and re-education are ongoing and will continue until all staff are trained. Staff members who were unavailable to attend the in-service/training for any reason will be given an in-service before returning to work. A post-test was also provided to assess understanding and knowledge of the topics covered. Effective 4/25/2025, this in-service/training and re-education will be provided monthly for 4 months, then annually and as needed thereafter. On 4/25/2025, the Medical Director was notified of the incident, and QAPI was initiated by the Administrator to analyze and investigate the root causes of the deficient practices. On 4/26/2025, a new policy regarding the Secured Unit/Facility was reviewed with the Interdisciplinary Team (IDT) members, including but not limited to, the Administrator, Director of Nursing, Director of Staff Development. The new policy was reviewed and approved by the quality assurance meeting on 05/12/2025 and will incorporate the following guidelines: - Admission process - Environment considerations - Visitation procedures Action taken to identify all other residents: On 4/25/25, RN Supervisor/Social Service Director checked all Residents and conducted a headcount, verifying residents based on census to ensure all residents were accounted for and present in the facility, excluding residents in hospital on bed-hold. No residents were found to be affected by the deficient practice. On 4/26/2025, Licensed Nurses, the Medical Records Director, and Designee checked all residents to see if they were wearing identification wristbands. Four residents were found not to be wearing wristbands due to refusal. An IDT meeting was conducted to discuss residents' non-compliance, respecting their rights, and informing their physicians and responsible parties. Refusals to wear wristbands are addressed in the care plan. Also on 4/26/2025, the Social Service Director or Designee and Licensed Nurses evaluated all residents to ensure they felt safe and secure in the facility using a safety/wellness evaluation tool. No residents were affected by this deficiency. Process and action taken to prevent recurrence: 1. The facility will assign a staff member to monitor the reception area daily, 7 days a week, to oversee the front lobby and monitor individuals entering and exiting. The assigned receptionist will inform the Social Service Director and/or Designee five times a week (Monday-Friday), and the "Manager of the Day" on weekends, as coverage. An alarm has been installed on the main entrance door to alert staff when someone enters or exits, especially in the absence of the receptionist or staff manning the front lobby. 2. Visitors will sign in and record the date/time of the visit, reason for the visit (destination), prior to entering the facility, and will sign out when leaving. Visitors may be required to present a photo ID to verify their identity before entry. 3. Visitors will wear a visitor sticker for identification during their visit. They may be asked to show a photo ID if they refuse or lose the sticker, or if there is a need to confirm their identity against the visitor log and Resident ID system (e.g., wristband). 4. Effective 4/25/2025, the Administrator installed a buzzer at the gate to alert staff when assistance is needed at the gate area to identify individuals wanting to leave before exiting. The Administrator/Designee will check the buzzer's function randomly twice a week for three months, then monthly thereafter. If the buzzer malfunctions, Maintenance will replace it immediately. After hours, RN Supervisor will be informed for assistance. 5. Staff will use the buzzer to alert Licensed Nurse/RN Supervisor for assistance in identifying and/or assisting individuals leaving the premises, verifying with the physician if out-on-pass is permitted, and whether the Resident is leaving with an authorized person. 6. The Administrator will review the visitor's log randomly twice a week for three months, then weekly, to ensure proper sign-in/out and purpose documentation. 7. RN Supervisor/Designee will apply an ID wristband upon admission or readmission of Residents, including taking a photograph to upload into the Resident's electronic records (PCC). 8. A GREEN wristband will be provided to Residents who are ambulatory without assistance to identify them and alert staff about the risk of elopement, especially near exit doors. 9. The Administrator will schedule random room rounds five times a week (Monday-Friday) for three months, then three times a week thereafter, assigning at least three rooms per Department Head or IDT member for inspection. The "Manager of the Day" on weekends will conduct additional random room inspections, including checking if Residents are wearing wristbands. 10. Licensed Nurses will conduct visual monitoring every 30 minutes for 72 hours to check on newly admitted Residents' whereabouts, activity, and behavior. Monitoring performance to ensure correction is achieved and sustained: Findings from monitoring reports will be reviewed and presented to QA monthly for further resolution and recommendations. Any issues of non-compliance will be reviewed by the QA Committee for additional actions until no negative trends are observed and 100% compliance is maintained for three consecutive months. The Administrator and/or Director of Nursing will oversee ongoing compliance. How corrective action will be accomplished for residents affected by the deficient practice: The Administrator completed 40 CEU units for license renewal on 04/27/2025. The renewal application and payment were mailed to the CDPH Licensing Department on 04/28/2025, pending review and approval. How the facility will identify other residents at potential risk and take corrective action: All residents within the facility have the potential to be affected by the deficient practice. On 04/28/2025, the Regional Director of Operations provided an in-service to the Administrator on maintaining licensure and addressing disciplinary actions for deficiencies.
Removal Plan
- The Administrator gave a disciplinary action and suspended RNA 1 pending investigation.
- Registered Nurse (RN) 1, Licensed Vocational Nurse (LVN) 1, and 2 local police officers located Resident 1 in Resident 1's apartment, approximately 7.8 miles away from the facility.
- RN 1, LVN 1, and 2 local police officers accompanied Resident 1 back to the facility. RN 2 completed Resident 1's skin assessment and noted a scab on Resident 1's left knee.
- Resident 1 was transferred to General Acute Care Hospital (GACH) 1 for further evaluation.
- The DON, the Quality Assurance (QA) Nurse Consultant, and the Director of Staff Development (DSD), conducted a series of in-services to staff regarding 'Safety and Supervision of Residents,' 'Elopement,' 'Missing Person,' and 'Resident Identification' policies, emphasizing: a) Identifying and confirming with Licensed Nurses, RNs, the Administrator, or Receptionist that the person leaving the facility is a visitor and not a resident before allowing anyone to leave the secured premises; b) Supervising residents while in the facility and always being mindful of their whereabouts; c) Identifying residents by checking for ID wristbands or another form of identification such as a photograph; d) Immediate action and interventions such as initiating a code to initiate search immediately once a resident was found missing; e) Seeking assistance from the Local Police Department in searching for a missing resident.
- LN, Medical Records Director, and Designee checked all residents to see if in-house residents were wearing ID wristbands. Four residents who refused were addressed in their care plans after an Interdisciplinary meeting.
- The Social Service Director (SSD) or designee and LNs evaluated all residents to see if the residents feel safe while in the facility using the safety/wellness evaluation tool. No other resident was found to be affected by the deficient finding.
- The IDT members comprising of the Administrator, the DON, and the DSD reviewed a new policy pertaining to secured unit/facility integrating the guidelines on admission process, environment special consideration, and visitation: a) The RN or Licensed Designee will immediately apply an ID wristband to a resident upon admission and upload a photograph in the resident's electronic health record; b) Green colored ID wristbands will be provided to residents who are ambulatory without assistance for identification and to alert staff about the risk for elopement; c) The Administrator will assign Department Heads or IDT members to conduct room inspections and check residents for ID wristbands, and assign a 'Manager of the Day (MOD)' on weekends to conduct random room inspections; d) LNs will conduct visual monitoring every 30 minutes for 72 hours to check newly admitted residents' whereabouts, activities, and behaviors; e) The facility will assign a staff member to monitor the reception area daily seven days a week, and an alarm has been installed on the main entrance door to alert staff when someone is entering or exiting in the absence of the receptionist.
Failure to Monitor Blood Glucose After Resident's Absence
Penalty
Summary
A deficiency occurred when the facility failed to measure a resident's blood sugar upon their return after an absence of approximately 24 hours. The resident, who had diagnoses including diabetes mellitus, hypertension, hyperlipidemia, and dementia, was prescribed insulin and oral medication for diabetes management. After being admitted, the resident left the facility without authorization and was missing for about a day. Upon being located and returned to the facility, the resident was provided a meal, but licensed staff did not check the resident's blood glucose level before the meal, despite the resident's risk for hypoglycemia or hyperglycemia due to missed medications and prolonged absence. Interviews with nursing staff and the Director of Nursing confirmed that blood sugar should have been measured upon the resident's return, in accordance with the facility's policy for residents receiving insulin who have had a significant absence. The failure to perform this assessment was not in line with professional standards of practice and the facility's own procedures for managing residents with diabetes.
Plan Of Correction
F-684 Immediate Corrective Action: On 04/26/2025, the Director of Nurses followed up with General Acute Hospital regarding resident's condition. Obtained information that resident was medically clear at Emergency Department and was admitted at Gero-psychiatric floor for further evaluation as gravely disabled. Based on ER records, resident blood sugar level was within normal range. Action taken to identify all other residents having the potential to be affected by the deficient practice and corrective action taken: On 04/27/2025, ADON and RN supervisor reviewed all diabetic residents' charts who required blood sugar check via fingerstick. All residents' blood sugar via fingerstick were checked as ordered. No other residents were affected by the same deficiency practice. Process and action taken to ensure deficient practice does not reoccur: On 04/27/2025, the Director of Nurses conducted an in-service with the licensed nurses on the importance of checking blood sugar level via fingerstick for residents with diagnosis of diabetes to prevent occurrence of hypoglycemia and to manage episodes of hyperglycemia. Additionally, on 04/27/2025, the DON conducted a 1:1 in-service with RN1 regarding the emphasis of checking blood sugar via fingerstick for residents with diagnosis of diabetes to prevent episodes of hypoglycemia and manage episodes of hyperglycemia. Monitoring performance to ensure that correction is achieved and sustained: The ADON/RN supervisor will randomly review residents' charts with diagnoses of diabetes to ensure that blood sugar check via fingerstick is done as ordered by MD. The ADON/RN supervisor will check charts of residents with diagnosis of diabetes every week for 3 months to ensure that all orders for fingerstick are followed as ordered by MD. As part of the facility CQI program, the DON will present a recapitulation of the RN supervisor's findings, which will be reviewed by the QAA committee monthly for the next three months for review and action as indicated. The DON will monitor compliance through review of monthly reports by the RN supervisor and ADON.
Administrator License Expired and Not Renewed
Penalty
Summary
The facility failed to ensure that the Administrator (ADM) held a current and active license as required by federal and state regulations. During an observation, it was noted that the ADM's license, posted in the facility's lobby, had expired. The expiration date on the license was confirmed, and during an interview, the ADM acknowledged that the license had expired and that the renewal application had not yet been submitted. The ADM also stated that the renewal application should have been submitted 60 days prior to the expiration date. A review of the facility's policy and procedure for the Administrator position indicated that the governing board is responsible for appointing an administrator who is duly licensed in accordance with current federal and state requirements. The failure to maintain a current and active license for the ADM resulted in the facility operating without a licensed administrator, which is not in compliance with regulatory requirements.
Plan Of Correction
What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not reoccur: Senior Director of Operations will do random rounds to the facility and check/monitor communication board to ensure that Administrator license is posted and up to date. How the facility plans to monitor performance to make sure solutions are sustained: Findings from monitoring reports will be reviewed and presented to QA monthly for further resolutions and recommendations. Any issues of non-compliance shall be reviewed by the QA Committee for additional actions and recommendations until no negative trends noted and/or 100% compliance has been achieved consistently x 3 months. Administrator and/or Director of Nursing will monitor this corrective action for continued compliance.
Incomplete Medical Records Due to Missing Physician Signatures
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for two residents, as required by federal regulations and facility policy. For one resident with a history of seizures, bipolar disorder, diabetes mellitus, and dementia, the informed consent (IC) form for a prescribed medication was not signed by the physician. The IC was only signed by the resident's responsible party and a licensed nurse, despite the facility's policy stating that the physician or prescriber must sign the form after explaining the necessary information to the resident or their representative. Both the Medical Records Director (MDR) and a registered nurse confirmed during interviews that the physician's signature was missing and acknowledged that it was their responsibility to ensure the form was properly completed. For another resident with diagnoses including psychosis, muscle weakness, and dementia, the attending physician did not review and sign the resident's Order Summary on a monthly basis, as required. Record reviews showed that the Order Summary reports for several months were unsigned by the physician. Both the MDR and a registered nurse confirmed that the physician should have signed the Order Summary each month to indicate approval of the resident's care orders. The Director of Nursing (DON) also stated that the MDR was responsible for ensuring timely audits and complete medical records, and that the physician should have reviewed and signed the Order Summary during follow-up visits, at least every 60 days. Facility policies reviewed during the investigation reinforced the requirements for complete, accurate, and objective documentation in the medical record, as well as the physician's responsibility to review and document the resident's total program of care at each visit. The failure to obtain the necessary physician signatures on both the informed consent form and the monthly Order Summaries resulted in incomplete and potentially inaccurate medical records for the two residents involved.
Plan Of Correction
F-842 Immediate corrective action: On 04/27/2025, the Director of Nurses assessed the resident for use of Depakote. Resident has been receiving Depakote as ordered by MD and as it was verified by nurses with Resident Representative. Action taken to identify all other residents: On 04/27/2025, other residents' consents were reviewed by Medical Records, but no other residents were affected by the same deficient practice. Process and action taken to ensure the deficient practice does not reoccur: On 04/27/2025, the Director of Nurses conducted an in-service with the Medical Record Director regarding the importance of signing consents timely that were verbally obtained from resident/resident representative by MD and verified by nurses. Monitoring performance to ensure that correction is achieved and sustained: The medical records will audit charts every month for 3 months to ensure that all informed consents are properly signed by MD. As part of the facility QAPI program, the DON will present a recapitulation of the Medical Record Director findings to the QAA committee monthly for the next month for review and action as indicated. The DON will monitor compliance through review of monthly reports by the Medical Record Director. Immediate Corrective Action: On 04/27/2025, the Director of Nurses reviewed the resident's medication summary: DON called and reviewed all medications with the Primary Care provider. Received order to continue all medications as ordered. No changes at this time needed. Action taken to identify all other residents: On 04/27/2025, other residents' order summaries were reviewed by Medical Records, and no other residents were affected by the same deficient practice. On 04/27/2025, the Director of Nurses conducted an in-service with the Medical Record Director regarding the importance of doctors signing order summaries in a timely manner. Monitoring performance to ensure that correction is achieved and sustained: The Medical Records will audit charts every month for 3 months to ensure that all ordered summaries are properly and timely signed by MD. As part of the facility CQI program, the DON will present a recapitulation of the Medical Record Director findings to the QAA committee monthly for the next three months for review and action as indicated. The DON will monitor compliance through review of monthly reports by the Medical Record Director.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to provide pharmaceutical services by not following the physician's orders for a resident, leading to a potential risk of the resident not receiving prescribed medications. The resident, who was admitted with acute respiratory failure, primary angle-open glaucoma, and unspecified vascular dementia, had severely impaired cognitive skills and lacked the capacity to make decisions. The physician's orders included medications for hyperlipidemia, glaucoma, pulmonary embolism, deep vein thrombosis, and chronic obstructive pulmonary disease. A review of the Medication Administration Record (MAR) for January 2025 revealed that on January 3, several medications were not documented as administered, including Atorvastatin, Brimonidine tartrate, Dorzolamide, Eliquis, Latanoprost, and Wixela. Interviews with the Registered Nurse, Director of Staff Development Assistant, Assistant Director of Nursing, and Director of Nursing confirmed that if the MAR was blank, it indicated the medications were not given. The Director of Nursing also noted that the weekly audit of the MAR was missed that week. The facility's policy and procedure for administering medications, last reviewed in July 2024, stated that medications should be administered in a safe and timely manner, in accordance with prescriber orders, and documented in the MAR. The policy also required that any withheld, refused, or delayed medications be noted in the MAR. The failure to adhere to these procedures resulted in the deficiency identified by the surveyors.
Unauthorized Medication at Bedside
Penalty
Summary
The facility failed to ensure that a resident was allowed to keep medications at their bedside without a physician's order. Resident 1, who was admitted with acute respiratory failure, generalized muscle weakness, and unspecified vascular dementia, was found to have a cold and flu medication bottle in their bedside drawer. The resident's Self-Administration of Drug assessment indicated they were unable to safely self-administer medication, and their cognitive skills for daily decisions were severely impaired. Despite this, the resident stated that a family member had brought the medication, and they had been taking it on their own. During observations and interviews, it was revealed that the facility staff, including a CNA and LVN, were unaware of the medication at the resident's bedside. The LVN stated that all medications should be in a locked medication cart and that family members should not leave medications at the bedside without the facility checking them first. The RN confirmed that no medications are allowed at a resident's bedside without a physician's order, and the resident was assessed as unable to take their own medication safely. The facility's policy and procedure on self-administration of medications require that the Interdisciplinary Team assess each resident's cognitive and physical abilities to determine if self-administration is safe. The policy also states that medications should not be left at the bedside unless authorized, and any unauthorized medications should be turned over to the nurse in charge. The Director of Nursing confirmed that there was no physician order for the resident to self-administer medication, and the medication could potentially interact with other medications the resident was taking.
Failure to Report Allegation of Financial Abuse
Penalty
Summary
The facility failed to report an allegation of family-to-resident financial abuse within the required two-hour timeframe to the State Survey Agency, the Ombudsman, and local law enforcement. This deficiency involved a resident who was admitted with acute respiratory failure, generalized muscle weakness, and unspecified vascular dementia, with severely impaired cognitive skills for daily decisions. The issue arose when a family member, identified as FM 2, reported that another family member, FM 3, was taking advantage of the resident's financial condition by withdrawing large sums of money from the resident's bank account. The Director of Nursing (DON) was informed by FM 2 about the potential financial abuse, but the facility did not report the allegation because they believed there was no proof of actual abuse, as the resident never went out with FM 3. The Social Service Director (SSD) also did not report the allegation, citing that the incident occurred before the resident's admission to the facility and lacked substantiation. The Administrator was not informed of the allegation, and the facility's policy required immediate reporting of any abuse allegations, which was not followed in this case. The facility's policy and procedure on abuse, neglect, exploitation, or misappropriation required that all allegations be reported immediately to the appropriate authorities. Despite this, the facility did not adhere to its policy, as the allegation was not reported within the specified timeframe. The failure to report the allegation of financial abuse placed the resident at risk for further abuse, as the facility did not provide the necessary protection by notifying the relevant authorities.
Failure to Develop Comprehensive Care Plan for Resident's Dietary Needs
Penalty
Summary
The facility failed to create a comprehensive care plan for a resident who refused facility food and received outside food delivery. The resident, who was admitted with acute respiratory failure, generalized muscle weakness, and unspecified vascular dementia, had severely impaired cognitive skills and lacked the capacity to make decisions. Despite these conditions, the facility did not develop a care plan addressing the resident's refusal of facility meals and the receipt of food from outside sources, as noted in interviews and record reviews. The Director of Nursing acknowledged that a care plan should have been created to manage the resident's food and oral intake, in accordance with the facility's policy on comprehensive, person-centered care plans. The facility's policy also indicated that if a resident is unhappy with their diet, a care plan should be developed to ensure satisfaction. The lack of a care plan for the resident's dietary preferences and refusals was identified as a deficiency, with the potential for delayed provision of necessary care and services.
Failure to Obtain Physician's Signature on Informed Consent
Penalty
Summary
The facility failed to ensure that the Attending Physician (AP) signed the consent for the use of a Merry Walker, a device designed to assist individuals with balance or walking difficulties, for one of the sampled residents. The resident, who was admitted with diagnoses including abnormalities of gait, generalized muscle weakness, and dementia, was unable to make decisions independently. The resident's cognitive skills were moderately impaired, and they were dependent on staff for various daily activities. Despite the necessity of informed consent for the use of the Merry Walker, the AP did not sign the consent form, which was acknowledged by the Medical Records Director and the Director of Nursing. The facility's policy requires that informed consent be obtained and signed by the physician before initiating the use of certain devices or treatments. The policy also emphasizes the physician's responsibility to disclose material information to the resident or their surrogate. However, the AP did not sign the informed consent form, even after being reminded with a red sticker. The Director of Nursing confirmed that the AP had visited the facility but did not sign the consent, highlighting a lapse in following the facility's procedures and policies regarding informed consent.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to provide meals that accommodated the food preferences of one resident, leading to a deficiency in care. The resident, who was admitted with acute respiratory failure, generalized muscle weakness, and unspecified vascular dementia, had severely impaired cognitive skills and lacked the capacity to make decisions. Despite this, the resident expressed a long-standing dislike for pasta, which was not documented or reflected in their meal preferences. During an interview, the resident stated they did not eat pasta when it was served, indicating a failure to accommodate their food preferences. The facility's policy required that individual food preferences be assessed upon admission and communicated to the interdisciplinary team. However, a review of the resident's records showed that their dislike for pasta was noted in the progress notes but not included in the registered dietitian's notes or on the meal ticket. The Director of Nursing acknowledged that the meal ticket should have reflected the resident's food dislikes, such as pasta, to ensure adequate nutritional intake. This oversight in documenting and communicating the resident's food preferences led to the deficiency identified in the report.
Failure to Follow Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices when a kitchen staff member, Cook 1, was observed not wearing a hair net while inside the kitchen. This incident was noted during an observation and interview with a staff member, who acknowledged that Cook 1 forgot to put on the hair net due to being busy. The Director of Nursing confirmed that kitchen staff are required to wear hair nets for infection control, as per the facility's policy and procedure on foodservice personnel, which mandates that hairnets or hats covering the hairline must be worn at all times. This oversight had the potential to compromise food integrity and posed a risk for foodborne illnesses among residents.
Incomplete Documentation of Financial Abuse Allegation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, which was identified during a survey. The resident was admitted with diagnoses including acute respiratory failure, primary angle-open glaucoma, and unspecified vascular dementia. The Minimum Data Set indicated the resident's cognitive skills for daily decisions were severely impaired. Despite this, the resident contacted the Ombudsman expressing concerns of financial abuse by a family member. The facility's records, however, did not accurately document all actions taken in response to these concerns. Specifically, the facility's Director of Nursing acknowledged that the Social Service Director had contacted the police regarding the financial abuse allegation, but this action was not documented in the resident's medical records. The facility's policy requires that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented accurately and completely. The lack of documentation regarding the police contact was a deviation from this policy, leading to incomplete medical records for the resident.
Inadequate Infection Control Practices in Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, particularly concerning influenza, for two of seven sampled residents. Licensed Vocational Nurse 1 (LVN 1) did not wear personal protective equipment (PPE) properly while attending to Resident 3. LVN 1's gloves were worn under the isolation gown, and the N95 mask was not fitted correctly, compromising the seal. Additionally, LVN 1 did not perform hand hygiene or change gloves after touching unclean surfaces, which could potentially spread infection. The Director of Nursing (DON) acknowledged that LVN 1's actions could lead to the spread of infection among residents. The facility also failed to ensure proper hand hygiene practices were followed by the Activity Assistant Coordinator (AAC) after providing care to Resident 5. The AAC was observed touching Resident 5 and other surfaces without performing hand hygiene, which could facilitate the transmission of infections. Furthermore, the facility's housekeeping practices were inadequate, as used cleaning cloths were placed on clean kitchen countertops, risking contamination of kitchen utensils used for resident dining. Additional deficiencies were noted in the use of PPE by other staff members. Housekeeper 2 (HKP 2) did not wear the N95 mask properly, and the Assistant Maintenance Supervisor (AMS) entered the facility without wearing an N95 mask. These actions were contrary to the facility's policies and procedures, which were designed to prevent the spread of infections. The DON confirmed that these failures in following the infection prevention and control protocols had the potential to spread infections to residents and staff.
Failure to Report Alleged Financial Abuse to Law Enforcement
Penalty
Summary
The facility failed to implement its policy and procedure for reporting alleged financial abuse involving a resident. On December 4, 2024, a resident alleged that a family member was misappropriating their funds, including taking their driver's license and bank card. Despite the resident's report and the facility's policy requiring notification of local law enforcement, the facility only reported the incident to Adult Protective Services, the Ombudsman, and the California Department of Public Health. The facility did not notify the police, which was a requirement under their policy for allegations of financial abuse. The resident, who was admitted to the facility with diagnoses including acute respiratory failure, muscle weakness, and major depressive disorder, reported the financial abuse to the Social Services Director. The resident's care plan included interventions to follow all reporting guidelines related to abuse reporting. However, the facility's failure to notify the police was acknowledged by both the Social Services Director and the Director of Nursing, who confirmed that the facility's policy required such notification. This oversight resulted in the resident's allegation not being investigated by local law enforcement.
Resident Subjected to Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nurse Assistant (CNA). The incident involved a resident with severe cognitive impairment and multiple diagnoses, including schizophrenia, cerebrovascular disease, dementia, and anxiety. On the day of the incident, a Registered Nurse (RN) heard a commotion and found the CNA being physically aggressive towards the resident. The resident was noted to have a skin tear on the right ear lobe after the incident. Witnesses, including two Activities Assistants and a Licensed Vocational Nurse, observed the CNA hitting the resident, causing the resident to fall. The CNA claimed the resident was attempting to hit her, but the CNA's actions were deemed inappropriate and classified as physical abuse. The facility's policy emphasizes the residents' right to be free from abuse, and the CNA's behavior was in direct violation of this policy.
Failure to Offer and Document Advance Directives
Penalty
Summary
The facility failed to offer assistance with formulating an Advance Directive (AD) to one of four sampled residents, Resident 91, upon admission. Despite Resident 91 having an intact cognition as per the Minimum Data Set (MDS), the facility did not document any discussion or offer of assistance regarding ADs. The Social Services Assistant (SSA) and Registered Nurse 2 (RN 2) confirmed that the AD Acknowledgement Form was incomplete and that the resident's capacity to make decisions was not clarified with the physician. This oversight was attributed to the resident's diagnosis of dementia, which led to the assumption that the resident could not make decisions. The facility also failed to ensure that the medical records of three other residents, Residents 6, 118, and 114, were updated to show documented evidence that ADs were discussed. Resident 6 was admitted with conditions affecting brain function and respiratory health, yet there was no AD in the medical chart. The Director of Social Services (DSS) acknowledged the absence of an AD and stated that it was the department's responsibility to offer AD information within 72 hours of admission. Similarly, Resident 118, who had metabolic encephalopathy and other conditions, did not have an AD documented, and attempts to contact the resident's family were unsuccessful. Resident 114, diagnosed with Alzheimer's and other severe conditions, also lacked an AD in their medical chart. The facility's policy on ADs requires that residents or their representatives be informed about the right to formulate an AD and be offered assistance if needed. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and communication regarding ADs for the sampled residents. This failure to discuss and document ADs potentially compromised the residents' rights to have their healthcare wishes respected in emergency situations.
Failure to Obtain Proper Authorization for Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints without proper assessment and authorization. Specifically, the facility did not complete a Physical Restraint Assessment Form before applying both upper side rails as a restraint for a resident. Additionally, the facility did not obtain informed consent from the resident or their representative, nor did they secure an order from the attending physician prior to the application of the side rails as a restraint. The resident involved had been admitted with diagnoses including major depressive disorder, anxiety disorder, and a contracture of the right hand. The resident's care plan did not recommend the use of side rails, and assessments indicated the resident was at high risk for falls and injuries. Despite this, observations revealed that the resident was in bed with both upper side rails up, and staff confirmed that there was no physician order or informed consent for their use. Interviews with facility staff, including a CNA and RN, confirmed the absence of necessary documentation and orders for the use of side rails as restraints. The facility's policy required a physician's order, a physical restraint assessment, and informed consent before applying restraints, but these procedures were not followed. This oversight had the potential to restrict the resident's freedom of movement and posed risks of physical harm.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for several residents, leading to potential delays in necessary care and services. For one resident with PTSD, the facility did not create a care plan to address the resident's mental health needs, despite the resident's history of trauma and PTSD diagnosis. The Assistant Director of Nursing acknowledged that a care plan should have been developed to identify triggers and provide appropriate interventions, but this was not done, potentially leading to increased anxiety and depression for the resident. Another resident with type two diabetes mellitus was receiving insulin glargine injections, but the facility did not develop a care plan for the use of this medication. The lack of a care plan meant that staff were not adequately informed about the resident's insulin regimen, which could result in delays in the delivery of necessary care. A registered nurse confirmed that a care plan should have been developed within seven days of the MDS assessment to ensure proper management of the resident's diabetes. Additionally, the facility failed to implement a care plan for a resident using physical restraints, specifically side rails. The resident's medical chart lacked a physician's order, a physical restraint assessment, and informed consent for the use of side rails as restraints. The Director of Nursing emphasized the importance of obtaining these documents to ensure the safe and appropriate use of restraints and prevent potential injuries. The facility's policy required a comprehensive care plan to be developed for each resident, but this was not followed in these cases.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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