Mainplace Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Orange, California.
- Location
- 1835 West La Veta Avenue, Orange, California 92868
- CMS Provider Number
- 555259
- Inspections on file
- 45
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Mainplace Post Acute during CMS and state inspections, most recent first.
A resident who was cognitively intact repeatedly refused showers, but staff did not document these refusals in progress notes or develop a care plan as required by facility policy. Nursing staff and medical record personnel failed to follow up on missing shower documentation, resulting in the absence of an individualized plan to address the resident's needs and preferences.
A resident with a new rash on both hands did not receive a documented change of condition assessment or required monitoring, despite a physician's order for antifungal treatment. Nursing staff confirmed that the necessary assessment, documentation, and care plan updates were not completed according to facility policy.
A resident with severe cognitive impairment and recent pituitary surgery did not receive a prescribed hydrocortisone taper because the medication order was not transcribed from hospital discharge paperwork into the facility's electronic record. The required double-check by nursing staff was not documented, resulting in the resident missing scheduled doses of the steroid.
A resident's right to manage their financial affairs was violated when the facility deposited their social security checks into the RFMS account without consent. Despite being cognitively intact, the resident was not informed or involved in the decision-making process, leading to a loss of control over their funds. The Business Office Director confirmed the lack of a formal agreement and communication, and the DON verified these findings.
A resident's medical record was incomplete and inaccurately documented, missing critical information such as lung sounds, blood pressure follow-up actions, meal intake percentages, and monitoring for urinary tract infection and diuretic side effects. These documentation gaps were confirmed by the RN Unit Manager during a review.
The facility failed to provide appropriate respiratory care for five residents, including improper maintenance of a CPAP machine, incorrect oxygen administration rates, and unsanitary storage of respiratory equipment. These deficiencies highlight a lack of adherence to physician orders and infection control protocols, potentially affecting residents' respiratory health.
The facility failed to ensure residents were free from unnecessary psychotropic medications. One resident's PRN antipsychotic order exceeded 14 days without proper evaluation, while another did not receive non-pharmacological interventions before medication administration. A third resident's records lacked documentation of required interventions, and another resident did not have informed consent or proper monitoring for medications. These deficiencies were confirmed by facility staff.
The facility failed to serve food at appropriate temperatures, affecting its palatability and nutritional value. During a tour, residents reported that hot foods were not served hot. A trayline observation showed that the plate warmer was overfilled, preventing proper heating. A test tray confirmed that several hot food items were below the required temperature. The DSS acknowledged that the current methods were insufficient to maintain hot food temperatures.
The facility failed to meet sanitary requirements in the kitchen, with issues such as improper labeling of food, utensils in disrepair, and inadequate air-drying of equipment. Observations included unlabeled turkey meat, utensils with melted handles, and wet equipment stored improperly. These deficiencies were confirmed by the DSS and acknowledged by the DON and RD.
The facility failed to inform physicians when residents were prescribed antibiotics without meeting McGeer's Criteria for a true infection, affecting several residents. This oversight was contrary to the facility's Antibiotic Stewardship Program, which aims to ensure appropriate antibiotic use. The Infection Preventionist did not document notifications to physicians, and the Director of Nursing acknowledged these findings.
Two residents were found self-administering medications without proper assessment or physician's orders. Resident 98 had topical medications at the bedside, while Resident 11 had eye drops. The facility failed to document care plans or conduct assessments for their ability to self-administer, contrary to policy. Staff interviews confirmed the lack of necessary procedures, posing a risk of inappropriate medication use.
A resident experienced a change in condition with symptoms of vomiting, abdominal discomfort, and refusal to eat. The facility failed to promptly notify the physician and conduct a thorough assessment, leading to a deficiency. Initial vital signs were taken, but no further monitoring or reassessment was documented. The resident's condition worsened, and they were found unresponsive and expired. Interviews with staff revealed awareness of the situation but a lack of timely action.
A resident with pressure injuries did not receive a physician-ordered low air loss mattress, and weekly assessments of the injuries were not conducted as per facility policy. Staff interviews confirmed lapses in communication and documentation, contributing to the deficiency in care.
A resident with a history of falls and assessed as high risk did not have floor mats placed on both sides of their bed as ordered by the physician and outlined in their care plan. This oversight was confirmed by RN 3 and acknowledged by the DON, indicating a failure to adhere to the facility's fall management policy.
The facility failed to manage pain appropriately for two residents. One resident received acetaminophen for pain levels that required tramadol, without informing the physician. Another resident did not receive non-pharmacological interventions before narcotic medication as ordered. Staff interviews confirmed these deficiencies.
A Pharmacy Consultant failed to identify an irregularity in a diabetic resident's medication regimen review, as the resident did not have an HbA1C test for 10 months despite being on insulin. The facility's policy required monthly reviews to identify irregularities, but no recommendations were made regarding the HbA1C test. The DON acknowledged the oversight and the potential complications from not monitoring HbA1C levels.
A facility failed to ensure proper medication storage and labeling, as medications were found at a resident's bedside without a physician's order or care plan. Additionally, an expired culture swab was discovered in a treatment cart, which had not been removed during a previous check. Staff interviews confirmed these deficiencies.
A facility failed to maintain safe infection control practices when an LVN used inappropriate wipes to clean a wrist blood pressure monitoring device with a Velcro cuff. The wipes were intended for hard, non-porous surfaces, not suitable for the cuff. The LVN confirmed the misuse and acknowledged the potential for spreading germs and bacteria.
A resident did not receive the pneumococcal vaccine despite consent being obtained, as the facility's IP failed to administer it within the expected timeframe due to being busy during influenza season. The DON acknowledged the oversight.
A resident's room was found to be in disrepair, with scratches and chipped paint on the wall adjacent to the bed. The resident expressed a desire for a neat and clean environment, as she spent a lot of time in her room. The DON was informed and verified the findings.
A resident's care plan for continuous oxygen therapy was not followed, as the resident received oxygen at four liters per minute instead of the prescribed two liters per minute. This discrepancy was confirmed during an observation and interview with an LVN, highlighting a failure to adhere to the care plan and physician's order.
The facility failed to properly store garbage in one of its dumpsters, as the right-side lid was missing, exposing the contents. The Maintenance Director confirmed the lid had been broken since August 2024 and was awaiting repair or replacement by the garbage company. Despite this, the dumpster was still in use, and the issue was acknowledged by the RD, DSS, and DON.
The facility did not provide adequate communal dining space for residents who do not require staff assistance with meals. During a resident council meeting, several residents expressed that only those needing assistance could access the communal dining area, limiting their socialization opportunities. The administrator acknowledged the issue and mentioned plans to address it.
A facility failed to develop comprehensive care plans for two residents, omitting a problem statement for breast cancer treatment with Femara and lacking measurable timeframes for mobility goals. This posed a risk of inconsistent care, as confirmed by the DON.
A resident was not informed or given the right to choose when the facility changed his weekly outpatient psychiatric services to monthly in-house services. The resident, who was cognitively intact and capable of making decisions, expressed that he did not agree with the change and would have preferred to continue with his outpatient services. The facility's failure to communicate and obtain consent was confirmed by staff interviews and acknowledged by the DON.
A resident's physician-ordered lab tests were delayed by seven days, and critical abnormal results were not promptly reported to the physician. The resident was later diagnosed with acute renal failure, and the delay in reporting and treatment had the potential to adversely affect the resident's health.
A resident with multiple medical conditions left the facility AMA without receiving appropriate discharge instructions or notifying the physician in advance. The facility staff failed to follow the P&P, leading to potential risks for the resident post-discharge.
Failure to Develop Care Plan for Resident's Refusal of Showers
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing a resident's repeated refusals to shower or bathe. Despite the facility's policy requiring the interdisciplinary team to create a person-centered care plan that includes measurable objectives and timeframes for all identified needs, there was no care plan in place for the resident's ongoing refusals. The resident, who was cognitively intact and able to make decisions, had a documented history of refusing showers on multiple occasions, as evidenced by shower sheets and staff interviews. However, these refusals were not documented in the resident's progress notes, and no care plan was initiated to address the refusals or to outline alternative interventions or education efforts. Interviews with nursing staff and review of facility records confirmed that required documentation and follow-up actions were not completed. The assigned CNAs and licensed nurses did not consistently report or document the refusals as required by facility policy, and missing shower sheets were not followed up by medical record staff or the Director of Staff Development. The lack of a care plan for the resident's refusals meant that individualized, consistent care was not ensured, and the facility's own procedures for addressing such refusals were not followed.
Failure to Assess and Monitor Change in Skin Condition
Penalty
Summary
The facility failed to provide necessary care and services for a resident who developed a rash on both hands. According to the facility's policy, any change in a resident's condition, such as a new skin issue, requires a licensed nurse to perform and document an assessment, notify the physician and responsible party, and monitor and document the resident's condition for at least three days. In this case, a physician ordered miconazole nitrate cream to be applied to the resident's hands for the rash, but there was no documented evidence that a change of condition assessment or required monitoring was completed. Interviews with nursing staff confirmed that the assessment and documentation were not performed as required by policy. The resident involved was cognitively intact and able to make decisions, as indicated by a BIMS score of 13 and a recent history and physical examination. Despite the new order for antifungal treatment, the medical record lacked documentation of assessment, monitoring, or care plan updates related to the rash. Nursing staff acknowledged the omission, and the DON confirmed awareness of the findings during the survey.
Failure to Administer Steroid Taper as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to administer hydrocortisone (Cortef) as ordered for a resident who had recently undergone pituitary tumor removal and was readmitted from an acute care hospital. The resident, who had severe cognitive impairment and lacked capacity to make medical decisions, was discharged from the hospital with specific orders for a hydrocortisone taper. These orders included a series of scheduled doses to be administered over several days, starting with a 25 mg dose, followed by 20 mg and 10 mg doses, and then a maintenance dose of 5 mg every afternoon. Upon review, it was found that the hydrocortisone taper was not transcribed from the hospital discharge paperwork into the facility's electronic medical record. The process for admitting residents required the admission nurse to review and transcribe discharge orders, which were then to be double-checked by the night shift RN supervisor. However, the hydrocortisone order was missed during this process, and there was no documentation indicating that the required double-check or recapitulation of orders had been completed by the RN supervisor. Interviews with facility staff, including the RN, unit manager, pharmacy consultant, and DON, confirmed that the hydrocortisone order was present in the hospital discharge paperwork but was not entered into the facility's system or administered as prescribed. The pharmacy consultant explained the importance of a steroid taper and the potential effects of abrupt discontinuation, but the report did not document any specific adverse outcomes for the resident. The deficiency was substantiated by the lack of documentation and failure to follow the facility's policy and procedure for medication administration.
Plan Of Correction
How corrective action will be accomplished for those residents affected by the deficient practice: The Facility was made aware of the incident. MD was notified and transcribed the missing Hydrocortisone order. MD was notified of the incident, conducted an investigation, and completed an incident report. Initiated monitoring for resident 1. Resident remains in stable condition and no negative effects were noted on resident 1. How the facility will identify other residents having the potential to have been affected by the deficient practice and corrective action taken: The Medical Records Director/Designee conducted audits on all admissions on April 4, 7, 8, 9, 2025, and ensured that orders from the Hospital are carried out promptly. The DON conducted in-service to the Licensed Nurses on 4-4-25 regarding the admission process to ensure that discharge orders from the Hospital are being carried out correctly. The Admission nurse who failed to transcribe the Hydrocortisone was given 1:1 in-service and training on the admission process on 03-20-25 and guided on verification/comparing of hospital discharge orders and ensuring that each order is double-checked for accuracy and completeness. What measures will be put into place to ensure that the deficient practice does not recur: The Admission nurse will verify admission orders from the Hospital, review with the Attending Physician for accuracy, and transcribe to the resident's admission records. The RN Supervisor of the next shift will compare admission orders from the Hospital versus the ones on the resident's record. If noted with discrepancy, the MD will be notified for order clarification and will carry out the orders promptly. In addition, the RN Unit Manager/Designee will check again the next day if orders were carried out correctly by comparing orders and will sign the sheet to verify it was checked for accuracy. The DON/Designee will be notified of the findings for follow-up. How the facility plans to monitor its performance to make sure solutions are sustained: The facility will utilize QA tools every month for 3 months and quarterly thereafter. The results of the findings will be forwarded to the QA Committee monthly for follow-up and recommendations. The Designee will check again the next day if orders were carried out correctly by comparing orders and will sign the sheet to verify it was checked for accuracy. The DON/Designee will be notified of the findings for follow-up.
Failure to Uphold Resident's Financial Rights
Penalty
Summary
The facility failed to uphold a resident's right to manage their financial affairs, specifically concerning the handling of social security funds. Resident 2, who was cognitively intact and capable of making decisions, was not involved in the decision-making process regarding their financial affairs. The facility deposited Resident 2's social security checks into the Resident Fund Management Service (RFMS) account without the resident's knowledge or consent. This action was contrary to the facility's policy, which requires signed authorization from the resident or their authorized agent before making deposits into the RFMS account. The Business Office Director admitted that the facility did not inform Resident 2 about the deposits until after they were made and acknowledged the absence of a formal agreement allowing the facility to manage the resident's finances. The lack of documentation and communication resulted in Resident 2 losing control over their social security benefits, which were deposited without their consent. The Director of Nursing confirmed these findings, highlighting a significant lapse in the facility's adherence to its policies and procedures regarding resident financial rights.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure the medical record was complete and accurately documented for a resident, leading to several deficiencies. The resident's Medication Administration Record (MAR) did not include documentation of lung sounds from October 4 to October 10, despite physician orders requiring this information to be recorded every shift. Additionally, there was no documentation of nursing actions taken after a low blood pressure reading of 91/49 mmHg was recorded on October 20. The resident's meal intake percentages were also missing for several days in October, and there was no documentation of monitoring for signs and symptoms of a urinary tract infection, as required by the care plan. Furthermore, the resident was on Bumex, a diuretic, which required monitoring for side effects such as dehydration. However, there was no documentation indicating that the resident was monitored for these side effects. The RN Unit Manager confirmed these documentation gaps during a concurrent closed medical record review and interview. These failures in documentation had the potential to impact the resident's care needs, as their medical information was incomplete and inaccurate.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide appropriate respiratory care for five residents, leading to deficiencies in the management and maintenance of respiratory equipment. Resident 440's CPAP machine was not maintained according to the manufacturer's guidelines, and the physician's order for the CPAP settings was not clarified, leaving the resident without specific inspiratory and expiratory settings. Additionally, there was no documented evidence of regular cleaning of the CPAP tubing assembly and water tub, which is crucial for preventing germ growth. Resident 55 received continuous oxygen at an incorrect rate, as the staff administered four liters per minute instead of the prescribed two liters per minute. The physician's order lacked specificity regarding the amount of oxygen to be administered, leading to inconsistencies in care. Furthermore, the resident's nasal cannula was not stored in a sanitary manner, posing an infection control risk. Similar issues were observed with Resident 98, whose nebulizer mask was not stored in a clean bag, and Resident 101, whose nasal cannula was left hanging on the bedside drawer without proper storage. Resident 27's nasal cannula tubing was found on the floor, and the resident reported being off oxygen for two days despite having a physician's order for oxygen administration. The tubing was not stored in a sanitary manner, and there was a lack of adherence to infection control protocols. These deficiencies highlight the facility's failure to ensure proper respiratory care and equipment maintenance, potentially affecting the respiratory health and well-being of the residents.
Failure to Implement Non-Pharmacological Interventions and Limit PRN Orders
Penalty
Summary
The facility failed to ensure residents were free from unnecessary psychotropic medications, as evidenced by the cases of four residents. For one resident, the facility did not limit the PRN order for an antipsychotic medication to 14 days, and there was no documented physician evaluation or justification for extending the use beyond this period. Interviews with the RN and DON confirmed these findings, indicating a lack of compliance with the facility's policy on psychotropic medications. Another resident did not receive non-pharmacological interventions prior to the administration of psychotropic medications, despite having orders for such interventions. The resident's MAR showed regular administration of medications like mirtazapine, fluoxetine, and eszopiclone, but non-pharmacological interventions were documented only once. Interviews with nursing staff confirmed the absence of documentation for these interventions, highlighting a failure to adhere to the care plan. A third resident's records showed a lack of non-pharmacological interventions before administering medications for anxiety and depression. The MAR and progress notes lacked documentation of these interventions, which were supposed to be implemented as per the care plan. Additionally, another resident did not have informed consent or a gradual dose reduction attempt for melatonin, and there was no specific monitoring for side effects of mirtazapine and melatonin. The DON confirmed these deficiencies, indicating a failure to follow the facility's procedures for psychotropic medication management.
Deficiency in Serving Food at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that food was served at appropriate temperatures, impacting the palatability and nutritional status of residents. During an initial tour, three residents reported that hot foods were not served hot, with one resident specifically mentioning items like fried eggs, bacon, pancakes, waffles, and egg sandwiches. A trayline observation revealed that the plate warmer was overfilled, with plates stacked above the heated compartment, which did not maintain the necessary temperature for hot foods. A test tray observation confirmed that several hot food items, including Pacific Rim Pork Roast, Red Beans and Rice, and Carrots with Parsley, were served at temperatures below the facility's policy requirements. The Dietary Services Supervisor (DSS) acknowledged that the metal hot plates, which were supposed to keep food hot, were not in use due to parts being ordered. The DSS admitted that the current use of plate warmers was insufficient to maintain the required temperatures for hot foods by the time they reached the residents. The Director of Nursing (DON), Registered Dietitian (RD), and DSS were informed of these findings.
Sanitary Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to meet sanitary requirements in the kitchen, as observed during an inspection. The inspection revealed that food items in the refrigerator were not properly labeled or dated, specifically a container of turkey meat that lacked an opened or use-by date. This was confirmed by the Dietary Services Supervisor (DSS), who acknowledged that the individual responsible for storing the food should have labeled it appropriately. Additionally, the facility did not maintain kitchen utensils in good repair or sanitary conditions. Several portion servers were found with partially melted handles and chipped surfaces, which were verified by the DSS. Furthermore, utensils set to air-dry were found with food particles and residue, and the drawer holding clean utensils contained white dry particles and water droplets. These findings were confirmed by the DSS, who took the items to be washed. The facility also failed to ensure that equipment and utensils were air-dried before storage. A blender and multiple metal pans were observed still wet and stored improperly, which could lead to cross-contamination. The DSS confirmed these observations and acknowledged that the items should have been completely dry before storage. The Director of Nursing (DON), Registered Dietitian (RD), and DSS were informed of these findings.
Failure to Notify Physicians of Inappropriate Antibiotic Use
Penalty
Summary
The facility failed to inform the physician of residents prescribed antibiotics when their signs and symptoms did not meet McGeer's Criteria for a true infection. This deficiency was identified for five of 30 final sampled residents and 24 nonsampled residents. The failure to notify the physician had the potential risk for continued use of unnecessary antibiotics, which could result in adverse reactions and the development of antibiotic-resistant bacteria. The facility's Antibiotic Stewardship Program (ASP) was designed to promote appropriate antibiotic use and optimize infection treatment while reducing adverse events. The program included monitoring antibiotic use, summarizing resistance patterns, and assessing residents for infections using standardized tools. However, the facility did not adhere to its policy of notifying physicians when residents were prescribed antibiotics without meeting the infection criteria. The Infection Preventionist (IP) was responsible for conducting surveillance and completing a Surveillance Data Collection Form for each resident with signs of infection. The IP was supposed to notify the prescribing physician if the criteria were not met, but documentation of such notifications was not found for the residents in question. The Director of Nursing (DON) acknowledged these findings during an interview.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents, Resident 11 and Resident 98, were assessed for their ability to safely self-administer medications. Resident 98 was found with a tube of Preparation H and mometasone furoate at the bedside without a physician's order for self-administration. Despite having the capacity to make medical decisions, there was no care plan or assessment documented to address Resident 98's ability to self-administer these medications. Interviews with LVN 5 and the DON confirmed the absence of necessary documentation and procedures for self-administration. Similarly, Resident 11 had bottles of Lumify and Systane eye drops at the bedside, which she self-administered without a physician's order or assessment for self-administration. The medical record review showed no documentation of a care plan or assessment for Resident 11's ability to self-administer these medications. Interviews with LVN 10 and RN 3 revealed that they were unaware of the medications at the bedside and confirmed the lack of necessary orders and assessments. The facility's policy requires an interdisciplinary team assessment to determine if self-administration is clinically appropriate and safe. However, this process was not followed for Residents 11 and 98, leading to a potential risk of inappropriate medication use. The DON acknowledged the findings and the risk associated with medications being accessible at the bedside without proper authorization and assessment.
Failure to Timely Address Change in Condition
Penalty
Summary
The facility failed to conduct timely assessments and follow-up actions for a resident who experienced a change in condition. The resident, identified as Resident 138, had an episode of vomiting, abdominal discomfort, and refused to eat. Despite these symptoms, the facility did not promptly notify the physician or conduct a thorough assessment of the resident's abdominal pain. The initial vital signs were taken, but there was no documented evidence of subsequent monitoring or reassessment of the resident's condition. The facility's policy on significant change in condition requires that a nurse perform and document an assessment, notify the physician, and monitor the resident for at least three days. However, in this case, the physician was not notified until approximately three and a half hours after the change in condition was noted. Additionally, there was no evidence of further vital signs being taken or an assessment of the resident's abdominal discomfort, which was a critical oversight given the resident's symptoms. Interviews with facility staff, including an LVN, RN, and the DON, revealed that the staff were aware of the change in condition but failed to take appropriate and timely actions. The DON acknowledged the delay in notifying the physician and the lack of documented follow-up assessments. The resident's condition deteriorated, and they were found pale, cold, and clammy, with labored breathing, before being declared expired. This series of inactions and delayed responses contributed to the deficiency identified in the report.
Failure to Provide Pressure Ulcer Care and Equipment
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development and worsening of pressure injuries for Resident 840. The resident, who was unable to make medical decisions, was ordered by a physician to have a low air loss (LAL) mattress for wound management. However, observations on multiple occasions revealed that the resident did not have the LAL mattress in place as required. This lack of appropriate equipment was contrary to the facility's policy and the resident's care plan, which emphasized the use of pressure-relieving devices to prevent skin breakdown and promote healing. Additionally, the facility did not adhere to its policy of conducting weekly assessments of pressure injuries. The medical records showed inconsistencies in the documentation of the resident's pressure injuries, particularly the Stage 4 pressure injury on the thoracic spine, which was not assessed or documented as required on certain dates. This oversight in monitoring and documenting the resident's condition further contributed to the deficiency in care. Interviews with facility staff, including the LVN, SSD, and DON, confirmed the lapses in providing the LAL mattress and conducting proper assessments. The staff acknowledged the failure to follow up on the resident's need for the LAL mattress and the lack of documentation to support any follow-up actions. The DON verified that the facility should have provided the LAL mattress while waiting for insurance approval or delivery from the hospice company, highlighting a breakdown in communication and responsibility among the staff.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 91, was free from accident hazards by not placing floor mats on both sides of the resident's bed as ordered by the physician and outlined in the resident's care plan. This oversight was observed on two separate occasions, where Resident 91 was seen lying in bed without the required floor mats in place. The resident had a documented history of falls within the facility, with incidents occurring on multiple dates, and was assessed as being at high risk for falls. The care plan, which included the use of bilateral floor mats, was not adhered to, despite the resident's agreement with the plan. The facility's policy on fall management, revised in June 2018, mandates appropriate assessment and interventions to prevent falls and minimize complications. However, the failure to implement the physician's order for floor mats was confirmed during an interview with RN 3, who acknowledged the resident's fall history and the responsibility of supervisors to ensure fall interventions were followed. The Director of Nursing was also informed and acknowledged the findings, indicating a lapse in the facility's adherence to its fall management policy.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, Residents 85 and 98, as per the physician's orders and facility policies. For Resident 98, the facility did not administer pain medication according to the prescribed parameters. The resident was given acetaminophen for pain levels that exceeded the mild pain threshold specified in the physician's order. This occurred on multiple occasions, with pain levels recorded between 4 and 6, which should have warranted the administration of tramadol instead. There was no documentation indicating that the physician was informed of these deviations from the prescribed pain management plan. For Resident 85, the facility did not consistently implement non-pharmacological interventions before administering narcotic pain medication as ordered. The resident's care plan included various non-drug interventions such as repositioning, dim lighting, relaxation, distraction, music, and massage, which were to be attempted prior to administering Dilaudid. However, the medical administration records for August, September, and October showed that these interventions were not documented as being attempted before the administration of the narcotic medication on several occasions. Interviews with facility staff, including an LVN and the DON, confirmed these findings. The LVN acknowledged the administration of pain medication outside the ordered parameters for Resident 98, and the DON confirmed that such practices could lead to ineffective pain management. Similarly, an RN confirmed the lack of documentation for non-pharmacological interventions for Resident 85, which was acknowledged by the DON.
Pharmacy Consultant Fails to Identify Irregularity in Diabetic Resident's Medication Review
Penalty
Summary
The Pharmacy Consultant at the facility failed to identify an irregularity in the medication regimen review for a resident with diabetes who was on insulin. The resident did not have any HbA1C level checked for 10 months, despite the physician's plan to routinely check the HbA1C every three to six months. The facility's policy and procedure for Medication Regimen Review, revised in August 2017, required the pharmacist to review each resident's medication regimen monthly to identify irregularities and unnecessary drugs. However, the Pharmacy Consultant did not make any recommendations regarding the HbA1C test for the resident from December 2023 to October 2024. During an interview, the Director of Nursing (DON) acknowledged the findings and stated that the frequency of the HbA1C test depended on the physician's order, which was not present in the resident's records. The DON also noted the potential serious complications that could arise from not monitoring the HbA1C levels, such as diabetic ketoacidosis, sepsis, and potential death. The Pharmacy Consultant, during a telephone interview, mentioned that recommendations about HbA1C were not usually made for residents on insulin in the long-term care setting, as it was considered more meaningful in outpatient care settings.
Improper Medication Storage and Expired Supplies Found in Facility
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and treatment supplies, as evidenced by the observation of medications stored at the bedside of a resident without a physician's order or care plan. During an initial tour, a Licensed Vocational Nurse (LVN) observed a tube of CalaZinc cream, a spray bottle of Sea-Clens Wound Cleanser, and a tube of Critic-Aid skin paste in the bedside drawer of a resident. The resident's medical records did not show any physician's orders for these medications, nor was there a care plan addressing their use or storage at the bedside. Interviews with nursing staff confirmed that the medications were brought from home and that there was no authorization for their bedside storage. Additionally, the facility failed to remove expired treatment supplies from a medication cart. During an inspection of Treatment Cart 1, an expired culture swab was found, which had the potential to be ineffective or contaminated if used. The LVN responsible for the cart acknowledged missing the expired item during a previous check. The Director of Nursing (DON) confirmed that expired supplies should be immediately removed from the treatment cart to prevent potential risks.
Inappropriate Disinfection of Blood Pressure Cuff
Penalty
Summary
The facility failed to maintain safe infection control practices, as observed during a medication administration for a resident. A licensed nurse (LVN 1) was seen using Micro Kill One Germicidal Alcohol wipes to clean a wrist blood pressure monitoring device with a Velcro cuff. These wipes are intended for hard, non-porous surfaces, and not suitable for the blood pressure cuff, which is not a hard surface. LVN 1 confirmed the inappropriate use of the wipes and acknowledged that improper cleaning could lead to the spread of germs and bacteria, potentially causing serious health complications.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure the administration of the pneumococcal vaccine to a resident, identified as Resident 31, who was reviewed for immunizations. The facility's policy, revised in July 2023, mandates offering and administering vaccines, including pneumococcal, to eligible residents after obtaining consent. Resident 31, who lacked the capacity to make medical decisions, had a representative who consented to the pneumococcal vaccination on September 21, 2024. However, a review of the resident's immunization report on October 23, 2024, showed no evidence of the vaccine being administered. During an interview on October 23, 2024, the Infection Preventionist (IP) confirmed that the consent for the pneumococcal vaccine was obtained but the vaccine had not been administered. The IP explained that vaccines should be administered within five days of obtaining consent, but due to being busy during the influenza season, the pneumococcal vaccine was not given to Resident 31. The Director of Nursing (DON) was informed of these findings and acknowledged the deficiency.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for a resident, identified as Resident 102, who resided in Room A. During an observation and interview, it was noted that the wall adjacent to Resident 102's bed was in disrepair, with visible scratches and areas where the paint was chipped. Resident 102 expressed a desire for her room to be neat and clean, as she spent a significant amount of time there, and indicated that the wall needed repair and repainting. The Director of Nursing (DON) was informed of these findings and verified the condition of the room.
Failure to Implement Oxygen Therapy Care Plan
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident, identified as Resident 55, who was receiving continuous oxygen therapy. The care plan specified that oxygen should be administered at a rate of two liters per minute via nasal cannula if the resident's oxygen saturation levels were less than 90%. However, during an observation and interview with LVN 9, it was verified that the resident was receiving oxygen at a rate of four liters per minute, contrary to the physician's order and the care plan. The facility's policy and procedure, revised in May 2017, emphasized ensuring each resident receives quality care to maintain their highest practicable well-being according to the interdisciplinary comprehensive assessment and plan of care. Despite this policy, the discrepancy in the oxygen administration rate for Resident 55 was identified, posing a risk of not providing appropriate individualized care. The medical record review confirmed the physician's order and care plan, highlighting the failure to adhere to the specified oxygen administration rate.
Improper Garbage Storage Due to Broken Dumpster Lid
Penalty
Summary
The facility failed to ensure proper storage and coverage of garbage in one of its four dumpsters, which had the potential to attract pests and rodents that carry diseases. During an observation, it was noted that the right-side lid of one dumpster was missing, leaving the garbage exposed. The Maintenance Director confirmed that the lid had been broken since August 2024 and had not been repaired or replaced by the garbage company. Despite this, the dumpster continued to be used for garbage storage. The issue was acknowledged by the RD, DSS, and DON during a subsequent meeting.
Inadequate Communal Dining Space for Independent Residents
Penalty
Summary
The facility failed to provide sufficient space for communal dining for residents who did not require staff assistance with meals. During a resident council meeting, three residents expressed that only those needing assistance had access to the communal dining area, limiting their ability to socialize and affecting their quality of life. Residents expressed a desire for the option to eat in a communal setting rather than being confined to their rooms. The facility's administrator acknowledged the issue and indicated that efforts were underway to address the lack of communal dining space for these residents.
Deficient Care Planning for Residents' Medical and Mobility Needs
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, addressing their specific medical and mobility needs. For Resident 2, the care plan did not include a problem statement for breast cancer treatment with Femara, a hormone-based chemotherapy medication. Additionally, the care plan for Resident 2's limited physical mobility lacked a measurable timeframe for achieving the goal of requiring minimal assistance with mobility tasks. This oversight was identified during a medical record review and an interview with Resident 2, who confirmed the ongoing use of Femara for breast cancer treatment. Similarly, the care plan for Resident 3, who required partial to moderate assistance with various mobility tasks, also lacked a documented target date for achieving the goal of minimal assistance. This deficiency was confirmed during a review of Resident 3's medical records and an interview with the Director of Nursing (DON), who acknowledged that the residents' medications should have been included in their care plans. These failures posed a risk of not providing appropriate, consistent, and individualized care to the residents.
Failure to Inform Resident of Change in Psychiatric Services
Penalty
Summary
The facility failed to ensure that Resident 1 was informed in advance and given the right to choose his treatment services when the facility changed his outpatient psychiatry services to in-house psychiatry services. Resident 1, who was cognitively intact and had the capacity to make decisions, was not notified or consulted about this change. The resident had been receiving weekly outpatient psychiatric services, but the facility unilaterally switched him to monthly in-house psychiatric services without his knowledge or consent. This change was confirmed through interviews with the resident, the Case Manager, and the Social Services Director (SSD), who all verified that there was no documentation showing Resident 1 was informed or agreed to the change in services. Resident 1 expressed that he did not agree with the change and would have preferred to continue with his weekly outpatient psychiatric services. The Case Manager justified the change by stating that since the facility provided in-house psychiatry and psychology services, there was no reason to send the resident out weekly for his appointments. However, the lack of communication and failure to obtain Resident 1's consent for this change in his treatment plan was acknowledged by the Director of Nursing (DON) during a follow-up interview. This oversight had the potential to prevent the resident from participating in his treatment decisions, as required by the facility's policy on Resident Rights.
Failure to Provide Timely Laboratory Services and Report Abnormal Results
Penalty
Summary
The facility failed to provide the laboratory services for a resident as per the physician's order. The physician had ordered CBC, CMP, and HbA1C tests to be completed in the morning on 1/31/24, but these tests were not conducted until 2/8/24, seven days later. Additionally, the facility did not ensure that the abnormal laboratory test results were reported to the physician in a timely manner. The resident's lab results from 2/8/24 showed critical levels of BUN, Creatinine, and eGFR, which were not promptly communicated to the physician. The licensed nurse documented only one attempt to notify the physician on 2/9/24 and did not follow up further when the physician did not respond. The Medical Director was also not notified of the abnormal results when the primary physician could not be reached. The resident's medical record showed that the physician was finally notified on 2/12/24, at which point the resident was diagnosed with acute renal failure and ordered to start intravenous fluids for hydration. The delay in reporting the abnormal lab results and the subsequent delay in treatment had the potential to adversely affect the resident's physical health and well-being. Interviews with the RN and DON confirmed these findings and verified that the facility's policies and procedures were not followed in this instance.
Failure to Implement AMA Discharge Policy
Penalty
Summary
The facility failed to implement their policy and procedure (P&P) regarding discharge against medical advice (AMA) for one resident. The resident, who had a diagnosis of diabetes mellitus with ketoacidosis, dementia, Alzheimer's disease, and psychosis, left the facility AMA without being provided appropriate instructions, including the need to contact the physician immediately. Additionally, the physician was not informed of the resident's intention to leave AMA until after the resident had already left the facility. This lack of communication and failure to follow P&P had the potential to place the resident at risk for medical complications post-discharge. Interviews with facility staff, including the Nursing Supervisor, Social Services Director (SSD), and Director of Nursing (DON), confirmed that the resident and their caregiver were not given the necessary discharge instructions. The caregiver had previously indicated an inability to care for the resident at home, and the facility's failure to notify the physician and provide proper discharge instructions contributed to the resident's unsafe departure. The DON and Case Manager arranged transportation for the resident without ensuring the caregiver was prepared to receive them, further complicating the situation.
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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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