Meadowood Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clearlake, California.
- Location
- 3805 Dexter Lane, Clearlake, California 95422
- CMS Provider Number
- 555490
- Inspections on file
- 30
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Meadowood Nursing Center during CMS and state inspections, most recent first.
A resident with substance dependence and no memory impairment had a physician’s order for Suboxone sublingual film three times daily for opioid dependence. Over two days, three ordered doses were not administered because the medication was unavailable, with documentation indicating the drug was pending pharmacy delivery and the order was awaiting physician signature. The resident reported not receiving Suboxone for about a week and experiencing shaking and anxiety, and the ADON confirmed the missed doses and lack of medication availability, acknowledging this as a significant medication error in light of facility policies requiring timely provision of medications and an environment free of significant medication errors.
A resident with HTN and Type II DM, who had a physician order indicating capacity to understand rights and make decisions, requested to leave the facility one evening but was not allowed to discharge. Nursing staff told the resident it was too late, cited safety concerns, and did not know the discharge procedure, and no administrative staff were contacted. The resident was not offered a release of responsibility form as required by facility policy for discharges without physician approval. Multiple staff, including the SSD, ADON, and DSD, later confirmed the resident was responsible for his own decisions and should have been allowed to leave, and the resident reported feeling very upset and frustrated when his request to go home was denied.
A resident with HTN and Type II DM was suspected by multiple staff and the resident’s son to be experiencing financial exploitation by a caregiver who held and possibly used the resident’s credit card. The SSD, ADON, and an LN each acknowledged that the situation constituted suspected financial abuse that warranted reporting, but no report was made to law enforcement, the LTC ombudsman, or CDPH. This inaction conflicted with the facility’s abuse and exploitation policy and state mandated reporting requirements, which require identification, investigation, and timely reporting of suspected abuse or exploitation by any individual.
A resident admitted with unsteadiness in feet and dysphagia had an active physician order for an alternating pressure pad (APP) mattress, but surveyors observed the resident on a regular mattress. Nursing staff acknowledged that physician orders must be followed, confirmed the resident had fragile skin and was at risk for pressure ulcers, and the ADON verified the APP order had not been implemented despite a Braden score indicating risk. Facility policies required use of appropriate support surfaces based on risk factors and adherence to prescribers’ orders, but no specific policy on physician orders was provided when requested.
A medication security deficiency occurred when an LN left a hall medication cart unlocked and unattended while inside a resident’s room, with no other staff present to monitor the cart. The LN later confirmed the cart had been left unlocked, despite facility policy requiring carts to remain closed and locked whenever out of the nurse’s sight. The ADON also confirmed that policy mandates locking unattended carts to prevent unauthorized access to medications, and the written medication administration P&P specifies that the cart must be kept closed and locked when not in direct view of the medication nurse or aide.
Two residents experienced lapses in infection control when staff failed to follow facility policies. For one resident with unsteadiness and dysphagia, an LN picked up three pillows from the floor and placed them back on the bed, despite leadership acknowledging that items on the floor are considered contaminated. For another resident with COPD and emphysema receiving scheduled nebulizer treatments, the nebulizer mouthpiece was left on a bedside dresser near beverages and a used cup instead of being rinsed, disinfected, and stored in a labeled plastic bag as required by facility policy. These actions did not comply with the facility’s infection prevention and nebulizer equipment procedures.
A resident with a PICC line and orders for daily heparin flushes and shift-based monitoring for infection did not have these treatments and assessments consistently documented on the MAR over multiple days. A non-RN licensed staff member reported he could not perform the flushes himself and only reminded RNs, with no confirmation they completed the tasks, and PICC site monitoring was not consistently charted. The resident stated that PICC care occurred less than half as often as ordered despite repeated reminders, and the DON confirmed that missing documentation meant the ordered PICC line care was not completed.
A resident with a diagnosis of left eye keratitis did not receive several prescribed doses of an ophthalmic solution, and there was no documentation in the MAR or medical record explaining why the medication was not administered. Interviews with the DON and Administrator confirmed that this lack of documentation did not meet facility policy, which requires reasons for missed medications to be recorded.
A resident with a history of cellulitis and venous insufficiency had acetaminophen left at her bedside without a physician's order for self-administration, resulting in the medication not being taken and her condition worsening. Additionally, staff were found to have pre-prepared medications for multiple residents, leaving unidentified medications in the medication cart, with the DON aware and instructing staff to supervise administration of these pre-prepared doses. These actions were not in accordance with facility policy and increased the risk of medication errors.
A resident with a history of cellulitis and venous insufficiency experienced a significant change in condition, including high fever, altered mental status, and worsening leg redness. Despite these symptoms being recognized by staff during the morning shift, the physician was not notified until several hours later. The delay in notification and lack of documentation led to delayed care and hospitalization for fever, altered consciousness, and sepsis, constituting neglect as defined by facility policy.
A nurse failed to maintain a resident's dignity and privacy during the administration of a rectal suppository by not stopping the procedure when the resident expressed pain and requested it be stopped, not ensuring privacy by leaving the curtain and door open, and not providing an adequate explanation of the procedure beforehand. The resident experienced pain, embarrassment, and psychological trauma as a result.
A registered nurse performed a digital stool dis-impaction on a resident without a physician's order during the administration of a rectal suppository, resulting in the resident experiencing pain, distress, and ongoing psychological trauma. The facility lacked adequate staff training, competency documentation, and policies regarding rectal medication administration and digital dis-impaction, leading to inconsistent practices among nursing staff.
A resident with a history of post laminectomy syndrome and constipation reported feeling violated after a nurse administered a rectal suppository in a manner the resident found inappropriate. Although facility policy required immediate reporting of abuse allegations within two hours, there was no evidence that the incident was reported to the Department within the required timeframe, and the Department did not receive notification until the following day.
A CNA solicited and received a debit card and PIN from a resident with multiple medical conditions, using the card to withdraw money after expressing financial hardship. The resident, who had no memory impairment, expected repayment but did not hear from the CNA afterward and reported feeling taken advantage of. Facility policy prohibits staff from accepting gifts, loans, or financial dealings with residents, and staff interviews confirmed awareness of these rules.
The facility failed to issue Notices of Medicare Non-Coverage (NOMNC) to two residents prior to their discharge, despite receiving Medicare Part A services. Staff interviews revealed a lack of clarity and accountability regarding the issuance of these notices, with key personnel unable to explain the oversight.
A resident with a history of pulmonary issues was using an Acapella device without a physician's order, contrary to facility policy. Staff interviews revealed a lack of awareness and oversight, as the device was not documented or ordered until noted by a surveyor. The facility's protocol required a physician's order for such devices, which was not initially obtained.
A resident sustained a left femoral fracture after a fall during a transfer using a mechanical lift, as only one staff member assisted instead of the required two. The staff member involved had not completed the necessary competency test for using the lift. The facility's policy, which mandates two staff for such transfers, was not followed, leading to the resident's injury.
Two residents in an LTC facility experienced injuries due to inadequate supervision and delayed response to call lights. One resident, requiring assistance for mobility, fell and fractured his arm after waiting over twenty minutes for help to use the toilet. Another resident, allowed to smoke unsupervised, sustained burns when his pants caught fire. Staff interviews revealed inconsistencies in following facility policies for call light response and smoking supervision.
A resident with chronic pain and a recent hip replacement experienced unmanaged pain due to the facility's failure to administer pain medication on time. The resident's medications, including Oxycodone and Norco, were frequently given late, contrary to the facility's policy of administering within one hour of the scheduled time. Interviews with staff confirmed the policy but revealed inconsistencies in its implementation, leading to the resident's significant discomfort.
The facility failed to provide scheduled showers to three residents, compromising their hygiene needs. A resident admitted for physical therapy after hip replacement did not receive showers for weeks, despite requiring partial assistance. Another resident with Alzheimer's and Parkinson's diseases, dependent on staff for showers, had no shower logs for two months. A third resident, needing setup assistance, reported not receiving showers for two weeks, leading to discomfort. Staff interviews revealed inconsistencies in providing showers outside scheduled days, and the facility lacked proper documentation, violating its hygiene policy.
Two residents experienced significant negative outcomes due to delayed call light responses in an LTC facility. One resident, requiring moderate assistance, fell and fractured an arm after waiting over twenty minutes for help. Another resident, needing substantial assistance, developed moisture-associated skin damage from prolonged exposure to moisture due to similar delays. Staff interviews confirmed the facility's policy of responding within five minutes was not consistently followed.
A resident in an LTC facility received pain medications Oxycodone and Oxycontin more frequently than prescribed, despite facility policies requiring verification of the right medication and dosage. The resident, with a history of chronic pain and recent hip surgery, was at risk due to these significant medication errors.
A resident's call light system was found to be non-functional, posing a risk of unmet needs. Despite daily checks, the issue was not reported or addressed until observed by staff. The resident, with cognitive intactness and requiring assistance, relied on another resident to signal for help. The malfunction was due to dirt obstructing the connection, which was resolved after cleaning.
A facility failed to accurately complete the MDS for a resident, resulting in incomplete information necessary for a resident-centered care plan. The resident, admitted with mobility issues, had an MDS indicating a BIMS score of 14, but key areas like eating and hygiene were not assessed. The MDS Coordinator acknowledged the inaccuracies, which contradicted the facility's policy on comprehensive assessments.
Missed Suboxone Doses Due to Untimely Reordering and Unavailability
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when prescribed Suboxone for opioid dependence was not available and not administered as ordered. The resident was admitted with a diagnosis of substance dependence and had no documented memory impairment. A physician’s order dated 2/4/26 directed Suboxone sublingual film 8-2 mg, one film three times daily for opioid dependence. Review of the medication administration record for 2/26 showed that the resident did not receive Suboxone on three occasions: one evening dose on 2/23/26 and two doses on 2/24/26, with the MAR coded as “other/see Nurse Notes.” Progress notes documented that on 2/23/26 the Suboxone was pending pharmacy delivery, and on 2/24/26 it was not given and was unavailable due to the order pending the physician’s signature, and later still pending delivery. During interview, the resident reported not receiving Suboxone for a week, stated he did not know why, and reported experiencing shaking and anxiety, noting he was a recovering heroin addict. The ADON, upon review of the MAR and progress notes, confirmed the three missed doses and that the medication had not been available for administration, and stated it was her expectation that medications be ordered timely and available so doses were not missed. She further agreed that, given the resident’s use of Suboxone for opioid dependence and his complaints of anxiety and shakiness due to missed doses, this constituted a significant medication error. Facility policies on Medication Reordering and Medication Errors stated that the facility would provide medications in a timely manner to meet each resident’s needs and ensure residents receive care in an environment free of significant medication errors.
Failure to Honor Resident’s Request for Discharge and Right to Self-Determination
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to self-determination when the resident’s request to be discharged was not granted. The resident was admitted in 11/2025 with diagnoses of essential HTN and Type II DM, and a physician order dated 11/11/25 indicated the resident was capable of understanding rights, responsibilities, and informed consent. On the evening of 1/28/26, the resident told the Social Services Director that he wanted to discharge from the facility. An Alert Note dated 1/29/26 at 12:46 a.m. documented that at approximately 8:30 p.m. on 1/28/26, the resident and a visitor requested an explanation as to why the resident could not leave the facility at that time. The nurse explained that per facility protocol and due to safety concerns, the resident was not cleared to leave and that a discharge care meeting could be arranged during normal business hours, and informed the visitor that leaving would be unsafe and against medical advice. Interviews and record reviews confirmed that, despite the physician’s order deeming the resident responsible for himself, staff did not allow him to discharge and did not offer a release of responsibility form as required by facility policy for discharges without physician approval. The Social Services Director, Assistant DON, and Director of Staff Development each verified that the resident was responsible for himself and had the right to leave the facility, and the Assistant DON confirmed that staff should have offered a release of responsibility form but did not. The nurse on duty stated she told the resident it was late, that nothing could be figured out at night, there was no administrative staff available, and she did not know the procedure or what to do, believing that allowing discharge at night would compromise safety. The resident later stated by telephone that he had wanted to go home at that time but was not allowed to do so and that he was really upset and frustrated. Facility policies on “Discharging a resident without Physician’s Approval” and “Resident’s Rights” indicated that residents requesting discharge without physician approval should be asked to sign a release of responsibility form and that residents have the right to self-determination.
Failure to Report Suspected Financial Abuse to Required Agencies
Penalty
Summary
The facility failed to report suspected financial abuse of a resident by the resident’s caregiver to law enforcement, the LTC ombudsman, or the State Agency (CDPH), despite multiple staff members forming suspicions of exploitation. The resident was admitted in November 2025 with diagnoses of essential HTN and Type II DM. The Social Services Director (SSD) reported that both she and the resident’s son believed the caregiver was taking advantage of the resident’s finances and expressed concern that the caregiver was holding the resident’s credit card. The SSD acknowledged she suspected financial abuse and agreed it should have been reported as such, but she did not report it because she believed the resident had an emotional attachment to the caregiver and the resident did not complain. The Assistant Director of Nursing (ADON) stated that concerns raised by the resident’s son about the caregiver keeping the resident’s credit card and being paid while the resident remained in the facility warranted further investigation and reporting to appropriate agencies. A licensed nurse (LN B) also stated she suspected financial abuse when she learned the caregiver had the resident’s credit card and believed the caregiver used it, and acknowledged these suspicions should have been reported to CDPH and the police. Review of the facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy and CDPH All Facilities Letter 21-26 showed that the facility was required to identify, investigate, and report all possible incidents of abuse, neglect, exploitation, or misappropriation of property, including suspected abuse by family, friends, or other individuals, to law enforcement, the LTC ombudsman, and CDPH. These required reports were not made in this case.
Failure to Implement Physician Order for APP Mattress for At-Risk Resident
Penalty
Summary
The facility failed to ensure services met professional standards of quality when a physician’s order for an alternating pressure pad (APP) mattress was not implemented for one resident. The resident was admitted in January 2026 with diagnoses including unsteadiness in feet and dysphagia. A physician’s order dated 1/16/26 directed that an APP mattress be placed on the resident’s bed. On 2/20/26, a licensed nurse stated that physician orders should be followed and that if an APP mattress was ordered, the facility should provide it; the nurse acknowledged that failure to follow the order meant facility policy was not followed and that residents would be at risk for further skin issues. During an observation in the resident’s room that same day, another licensed nurse confirmed the resident was on a regular mattress and not on an APP mattress, and stated the resident had fragile skin and was at risk for developing pressure ulcers. In a concurrent interview and record review with the ADON on 2/20/26, the ADON verified that the resident was not on an APP mattress despite the active physician order from 1/16/26. The ADON also confirmed the resident’s Braden score was 15, indicating the resident was at risk for pressure ulcers, and stated that using an APP mattress was a preventive measure to help prevent development of pressure ulcers. The facility’s policies indicated that appropriate support surfaces should be selected based on residents’ risk factors in accordance with current clinical practice, that medications are administered in accordance with prescribers’ orders, and that staff must demonstrate skills necessary to care for residents’ needs including skin and wound care. A policy specific to physician orders was requested but not provided.
Unattended Unlocked Medication Cart Left Accessible in Hallway
Penalty
Summary
The deficiency involves failure to keep medications secured in locked compartments as required by facility policy and professional standards. During an observation and interview on 2/20/26 at 5:14 p.m., a licensed nurse left the hall 1 medication cart unlocked while inside a resident’s room, and there were no other licensed or unlicensed staff present to monitor the cart. Upon returning, the nurse confirmed that the cart had been left unlocked and unattended and acknowledged that facility policy requires medication carts to be locked when unattended for resident safety. In a subsequent interview at 5:20 p.m., the assistant DON confirmed that medication carts are required by facility policy to be locked when unattended to prevent unauthorized access to medications, and review of the written medication administration policy dated 12/2025 showed it directs that the medication cart be kept closed and locked when out of sight of the medication nurse or aide. The report states that this failure could result in access to medications by unauthorized people, leading to medication theft and unauthorized medication ingestion with a risk of overdose, drug interactions, or severe adverse effects.
Failure to Follow Infection Control Practices for Bed Linens and Nebulizer Equipment
Penalty
Summary
The facility failed to maintain infection control measures for two residents when staff did not follow established policies and procedures. For one resident admitted in January 2026 with diagnoses including unsteadiness in feet and dysphagia, a licensed nurse was observed picking up three pillows from the floor and placing them at the foot of the resident’s bed. The Assistant Director of Nursing confirmed seeing the three pillows on the bed and stated that anything that fell on the floor was considered contaminated and should not have been placed back on the bed, describing such items as soiled or dirty. The facility’s Infection Prevention and Control Committee policy indicated that the committee was to assist in the development and implementation of written policies and procedures for the prevention and control of infections among residents, provide guidelines for a safe and sanitary environment, and review, establish, and monitor environmental infection prevention and control practices in accordance with CDC, HICPAC, OSHA, and local and state requirements. For another resident admitted in December 2022 with COPD and emphysema and an order for nebulized medication every eight hours, the nebulizer mouthpiece was observed resting on top of the bedside dresser, not stored in a container or bag to protect it from cross contamination, and placed near a soda and a used drinking cup. The resident stated that staff administered the nebulizer medication but rarely kept the mouthpiece inside the provided plastic bag. A licensed nurse verified that the mouthpiece was not kept inside the plastic bag as required by facility policy and stated that after use, the mouthpiece should be stored in the bag. The Director of Nursing also verified that the mouthpiece was not in the plastic bag and was on the bedside dresser, and stated this practice was not acceptable. The facility’s policy on administering medications through a small volume handheld nebulizer required that the nebulizer equipment be rinsed and disinfected according to facility protocol and stored in a plastic bag labeled with the resident’s name and date.
Failure to Follow PICC Line Flushing and Monitoring Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and facility policy for PICC line care for one resident. The resident was admitted with metabolic encephalopathy and bacteremia and had a physician order for the PICC line to be monitored every shift on the day shift for signs and symptoms of infection. Review of the Medication Administration Record (MAR) for February showed that this monitoring order was not documented as completed on multiple specified day shifts. The resident also had a physician order for a daily heparin lock flush solution to maintain PICC line patency, which was not documented as administered on several ordered dates and times. The facility’s policy required flushing catheters at regular intervals to maintain patency, monitoring for IV complications, and recording the date and time medications were administered in the medical record. During interviews, the licensed staff member who worked several of the shifts in question confirmed that documentation of PICC line care was missing from the MAR and stated that, as he was not an RN, he could not flush the line himself and instead reminded RNs to perform the task, but could not verify it was done without documentation. He also stated he monitored the PICC site daily, although this was not consistently documented. The resident reported that staff flushed and monitored the PICC line less than half of the required times and not daily, despite his repeated reminders, and stated he felt neglected and feared infection. The DON acknowledged that a PICC line not flushed consistently could become clogged, that lack of monitoring could miss a reaction or infection, and that if a task was not documented, it meant it was not completed, confirming the missing documentation on the resident’s MAR.
Failure to Document Reasons for Missed Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation regarding the administration of medication for one resident diagnosed with left eye keratitis. The resident's Medication Administration Record (MAR) showed that several doses of a prescribed ophthalmic solution were not administered on specific dates and times. However, there was no corresponding nursing documentation explaining the reason for the missed doses. The resident's medical record lacked any notes indicating why the medication was withheld, whether the physician was notified, or what follow-up actions were taken regarding the missed medication. Interviews with the Director of Nursing (DON) and the facility Administrator confirmed that the absence of documentation did not meet the facility's expectations or policy requirements. The facility's policy on medication administration documentation requires that reasons for withholding or not administering medication be recorded, along with any related follow-up. The deficiency was identified through record review and staff interviews, which verified that the required documentation was missing for the resident in question.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to ensure professional standards of nursing practice were followed in several instances involving medication administration. In one case, a resident with a history of cellulitis and peripheral venous insufficiency, who was cognitively intact according to her assessment, had acetaminophen left at her bedside by a licensed nurse without a physician's order for self-administration. The resident did not take the medication as intended, and her fever escalated, leading to her being found slumped and shivering, and subsequently transferred to the hospital with a diagnosis of fever and sepsis. The facility's policies required that self-administration be documented and approved by the care team, and that medications not be left unattended at the bedside, which was not followed in this instance. Additionally, the facility was found to have allowed the pre-preparation of medications for multiple residents. Staff interviews and record reviews revealed that medications were removed from their original packaging and placed in medication cups ahead of administration, with several cups containing unidentified medications left in the medication cart. Staff, including the Director of Staff Development and other licensed nurses, confirmed that this practice was not standard and posed a risk for medication errors, as it was unclear which medications belonged to which residents. The Director of Nursing was aware of these practices and, on at least two occasions, instructed staff to supervise the administration of these pre-prepared medications rather than discarding them and preparing new doses as per policy. Facility policies reviewed indicated that medications should be prepared and administered one resident at a time, with verification of the right resident, medication, dosage, time, and route. Medications were also required to be stored in their original containers until administration. The observed practices of leaving medications at the bedside without proper authorization and pre-preparing medications for multiple residents directly contravened these policies and increased the potential for medication errors and delays in care.
Delayed Physician Notification and Neglect of Change in Condition
Penalty
Summary
The facility failed to protect a resident from neglect by not promptly notifying the physician of a significant change in condition. The resident, who had a history of cellulitis and peripheral venous insufficiency, was admitted with minimal cognitive impairment. On the day of the incident, the resident exhibited a resting heart rate of 117 bpm, was shaking, and complained of being cold. Later, the resident developed an elevated temperature of 100.2°F, which progressed to a fever of 103.6°F and then 104.6°F, along with an altered level of consciousness and decreased oxygen saturation. Despite these symptoms, the physician was not notified until several hours after the initial signs of deterioration were observed. Multiple staff interviews confirmed that the resident's change in condition, including worsening redness in the leg and the development of a high fever, was recognized during the morning shift. However, the assigned nurse did not appear concerned and did not escalate the situation or notify the physician in a timely manner. The Director of Staff Development and the Director of Nursing both acknowledged that a fever is considered a change in condition that requires immediate physician notification, and that the delay in reporting constituted neglect. Documentation of the resident's symptoms, particularly the redness in the leg, was also lacking in the medical record. The facility's own policies require prompt notification of the physician and documentation of significant changes in a resident's condition. In this case, the delay in physician notification and inadequate documentation resulted in the resident experiencing delays in care, ultimately requiring hospitalization for fever, altered mental status, and sepsis. Staff interviews and record reviews confirmed that the facility did not follow its protocols, leading to the identified deficiency.
Failure to Maintain Resident Dignity and Privacy During Rectal Medication Administration
Penalty
Summary
A registered nurse (RN) failed to provide nursing care in a manner that maintained a resident's dignity and respect during the administration of a rectal suppository. The RN did not stop the procedure when the resident complained of pain and requested that the procedure be stopped. Instead, the RN continued to move her finger inside the resident's rectum for several minutes, stating it was necessary for the medication to dissolve, despite the resident's clear expression of discomfort and request to cease. Additionally, the RN did not ensure the resident's privacy during the procedure. The privacy curtain was not drawn, and the door to the hallway was left open, allowing others to see the resident partially unclothed from the waist down. This lack of privacy was confirmed by both certified nursing assistants (CNAs) present during or after the incident, with one CNA noting that the resident's buttocks were visible from the hallway. The RN also failed to adequately explain the procedure to the resident prior to performing the invasive rectal medication insertion. The facility's policy required staff to explain procedures, provide privacy, and respect residents' rights to refuse or discontinue treatment. The resident, who had intact cognitive skills and a history of depression but no other psychiatric diagnoses, reported feeling violated, embarrassed, and traumatized by the incident. The event resulted in the resident experiencing pain, anxiety, and ongoing psychological distress.
Failure to Follow Professional Standards in Rectal Medication Administration
Penalty
Summary
A registered nurse performed a digital stool dis-impaction procedure on a resident without a physician's order, which is not in accordance with professional standards of practice. The nurse inserted a rectal suppository and manipulated her finger inside the resident's rectum for several minutes, despite the resident expressing pain and asking for the procedure to stop. The nurse stated she was attempting to break up stool to allow the suppository to dissolve, and removed some stool during the process. The resident was prescribed a rectal suppository as needed for constipation, but there was no order for digital dis-impaction. The resident, who had a history of post laminectomy syndrome and constipation, reported feeling violated, embarrassed, and traumatized by the procedure. The resident's cognitive skills for daily decision-making were intact at the time of the incident. Witnesses, including a certified nursing assistant, confirmed that the procedure took significantly longer than usual and that the resident was visibly upset afterward. The resident later reported ongoing psychological distress, including nightmares and feeling unsafe in the facility. A review of facility records revealed that there was no documented competency or specific training for licensed nursing staff regarding rectal suppository administration or digital stool dis-impaction. The facility lacked a policy on digital dis-impaction, and staff interviews indicated inconsistent understanding of the correct procedures and requirements for physician orders. The facility's policy on rectal medication administration did not address digital dis-impaction, and the nurse involved believed such procedures did not require a physician's order.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the Department for one sampled resident. The resident, who had a history of post laminectomy syndrome and constipation, reported feeling violated after a registered nurse administered a rectal suppository, stating that the procedure took too long and caused discomfort. The incident was documented in the nursing notes, and the resident expressed his concerns during an interview, specifying the time and nature of the event. Despite the facility's policy requiring immediate reporting of abuse allegations within two hours, there was no evidence that the initial report was sent to the Department as required. The administrator was notified of the allegation by a charge nurse, who claimed to have faxed the report, but a review of the fax log showed no such transmission. The Department did not receive notification until the following morning, when the administrator sent the required form after confirming the initial report had not been received.
Misappropriation of Resident Property by Staff
Penalty
Summary
A certified nurse assistant (CNA) solicited and received a debit card and PIN from a resident who had diagnoses including polyneuropathy, intervertebral disc degeneration, arthritis, depressive disorder, chronic pain syndrome, and adult failure to thrive. The resident, who had no memory impairment, gave her card to the CNA after the CNA expressed financial hardship and requested a loan, with the understanding that the money would be repaid. After the transaction, the CNA did not return or communicate with the resident, prompting the resident to report the incident to facility staff. The resident expressed feeling taken advantage of and described emotional distress as a result of the incident. Facility policy, as outlined in the employee handbook and ethical house rules, strictly prohibits staff from accepting gifts, loans, or financial dealings of any kind with residents, including the removal of residents' personal belongings from the facility. Interviews with staff and the administrator confirmed that employees are not allowed to accept cash, bank cards, or any items of value from residents. The CNA involved admitted to taking the card and withdrawing money, which was in direct violation of facility policy and procedures.
Failure to Issue Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to two residents, resulting in a deficiency in beneficiary notification. Resident #244, who had a medical history of paraplegia, was admitted on June 27, 2024, and discharged home on August 19, 2024. The resident received Medicare Part A skilled services from July 11, 2024, to August 18, 2024. Despite the planned discharge and the end of Medicare coverage, the facility did not provide the required NOMNC to the resident. Similarly, Resident #245, with a medical history of rheumatoid arthritis, was admitted on September 20, 2024, and discharged on October 25, 2024. This resident also received Medicare Part A services from the admission date until October 24, 2024, but was not issued a NOMNC prior to discharge. Interviews with facility staff revealed a lack of clarity and accountability regarding the issuance of NOMNCs. The Biller and Business Office Manager were unable to explain why the notices were not provided. The Social Services Supervisor, responsible for issuing beneficiary notices, acknowledged that NOMNCs should be given two to three days before the last covered day of therapy services. The Director of Nursing and the Administrator also confirmed the expectation that NOMNCs be issued 48 hours prior to discharge, yet neither could account for the oversight. This deficiency highlights a breakdown in communication and procedure adherence within the facility's administrative processes.
Failure to Obtain Physician's Order for Respiratory Device
Penalty
Summary
The facility failed to obtain a physician's order for the use of a respiratory device, specifically an Acapella device, for a resident. The resident, who had a medical history of acute pulmonary edema and pulmonary hypertension, was observed using the device independently without a physician's order. The facility's policy required a physician's order for the use of such devices, and the device should be administered by a licensed nurse or respiratory therapist. Despite the resident's care plan indicating potential respiratory issues, the necessary order for the Acapella device was not obtained until after the surveyor's observation. Interviews with facility staff, including a Licensed Vocational Nurse and a Respiratory Therapist, revealed a lack of awareness and oversight regarding the resident's use of the device. The Respiratory Therapist acknowledged that the device was mentioned in a prior assessment but failed to secure a physician's order. The Director of Nursing and the Administrator confirmed that the facility's protocol required a physician's order for medical devices and that staff should have informed the nurse upon discovering the device at the resident's bedside. The deficiency was identified when the surveyor noted the device and prompted the facility to obtain the necessary physician's order.
Failure to Follow Mechanical Lift Policy Results in Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent a fall for a resident, identified as Resident 1, who required the use of a mechanical lift for transfers. The facility's policy mandated that at least two staff members assist with mechanical lift transfers to ensure safety. However, on the day of the incident, only one staff member, Unlicensed Staff A, assisted Resident 1 during a transfer from a wheelchair to a bed, which was against the facility's policy. Additionally, Unlicensed Staff A had not completed the required competency test for using the mechanical lift prior to the incident. This lack of training and failure to adhere to the facility's policy resulted in Resident 1 sustaining a fall, leading to a left femoral fracture. The resident, who had intact cognition and required maximal assistance for personal care, was later diagnosed with a left partial hip replacement following the injury. Interviews with various staff members, including the Director of Nursing, Licensed Staff, and other Unlicensed Staff, confirmed that the standard practice was to have two staff members present during mechanical lift transfers to prevent falls and accidents. The Assistant Director of Nursing acknowledged that the policy was not followed during the incident, which contributed to the resident's fall and subsequent injury.
Inadequate Supervision and Delayed Response Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure that Resident 1 was free from accidents due to delayed response to call lights. Resident 1, who required moderate assistance for transfers due to unsteadiness and mobility issues, fell twice while attempting to go to the toilet without staff assistance. The call light was not answered promptly, leading Resident 1 to wait over twenty minutes before attempting to transfer independently, resulting in a fall and a fractured right arm. Resident 2 was not adequately supervised while smoking, leading to cigarette burns on his right thigh and scrotum. Despite having a care plan that allowed unsupervised smoking, Resident 2's pants caught fire, and he sustained burns. The facility's smoking policy required supervision for residents with restricted smoking privileges, but Resident 2 was observed smoking without supervision or a smoking apron, contrary to the policy. Interviews with staff revealed inconsistencies in the implementation of the facility's policies regarding call light response and smoking supervision. Staff acknowledged the risks associated with delayed call light responses and unsupervised smoking, yet these policies were not consistently followed, contributing to the incidents involving Resident 1 and Resident 2.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to provide timely pain management for a resident who had undergone a left hip arthroplasty and suffered from chronic pain due to multiple surgeries. The resident reported experiencing excruciating pain because the nursing staff did not administer her pain medication according to the scheduled times. Specifically, the resident stated that it often took more than two hours to receive her pain medication after requesting it, leading to significant discomfort. A review of the resident's medical records revealed discrepancies in the administration of her prescribed medications. The Medication Administration Record (MAR) indicated that the resident was supposed to receive Oxycodone Hydrochloride ER 30 mg every twelve hours and Norco 10-325 mg every four hours. However, the Medication Administration Audit Report showed that these medications were frequently administered late, sometimes by several hours, which was contrary to the facility's policy of administering medications within one hour of the prescribed time. Interviews with the Director of Nursing (DON) and Licensed Staff D confirmed that the facility's policy allowed for medication administration within one hour of the scheduled time. However, the records indicated that this policy was not consistently followed, resulting in ineffective pain management for the resident. The DON acknowledged that there was a delay in the electronic medication administration record system but stated that it should not take an hour or more to save the nurse's signature. The failure to adhere to the medication schedule led to the resident experiencing unmanaged pain.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that three residents received showers on their scheduled days, which compromised their personal grooming and hygiene needs. Resident 5, who was admitted for physical therapy after a hip replacement, reported not receiving showers for several weeks. The Minimum Data Set (MDS) indicated that Resident 5 required partial assistance with showers, but the facility lacked electronic records to confirm whether showers were provided. The only documentation available showed a refusal on one occasion, with no further records for the month. Resident 7, diagnosed with Alzheimer's and Parkinson's diseases, was dependent on staff for showers. The facility did not provide any shower logs for Resident 7 for January and February 2024, indicating a lack of documentation and potential neglect in meeting the resident's hygiene needs. Similarly, Resident 6, who required setup or clean-up assistance, reported not receiving a shower for two weeks, leading to perineal itching. Despite being scheduled for showers twice a week, there was no documentation to confirm that these were provided, and the resident expressed dissatisfaction with the timing of the showers offered. Interviews with unlicensed staff revealed that showers were scheduled twice a week and as requested, but there was inconsistency in providing showers outside of scheduled days. The facility's policy stated that residents unable to perform activities of daily living independently should receive necessary services to maintain hygiene, yet the lack of documentation and resident reports indicate a failure to adhere to this policy. The absence of electronic records and incomplete shower logs further highlight the facility's deficiency in maintaining adequate hygiene care for its residents.
Delayed Call Light Response Leads to Resident Injuries
Penalty
Summary
The facility failed to adhere to its policy of responding to call lights within five minutes, as evidenced by the experiences of two residents. Resident 1, who required moderate assistance for transfers due to unsteadiness and mobility issues, fell twice while attempting to use the toilet without staff assistance. Despite activating the call light, Resident 1 waited over twenty minutes for assistance, leading to a fall that resulted in a fractured right arm. Observations confirmed that call lights were not answered promptly, with one instance taking eight minutes to respond. Resident 3, who was incontinent and required substantial assistance for transfers and hygiene, also experienced delays in call light response. This resident reported waiting over twenty minutes for assistance, resulting in prolonged exposure to moisture and the development of moisture-associated skin damage in the perirectal area. Interviews with staff confirmed that the facility's policy required call lights to be answered within three to five minutes, yet this standard was not consistently met. Interviews with facility staff, including unlicensed personnel and the Director of Staff Development, highlighted the expectation for call lights to be answered promptly to prevent safety issues. The facility's policy, dated September 2022, mandated that calls for assistance be answered within five minutes, with urgent requests addressed immediately. However, the failure to meet these standards led to significant negative outcomes for the residents involved.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of pain medications Oxycodone and Oxycontin. The resident, who had undergone a left hip arthroplasty and had a history of chronic pain due to multiple surgeries, was prescribed Oxycodone Hydrochloride ER 30 mg to be taken every twelve hours. However, records indicated that the medication was administered more frequently than prescribed, with doses given at 6:00 a.m., 8:00 a.m., and 9:00 p.m. on one occasion. Additionally, a subsequent order for Oxycontin 20 mg to be taken every twelve hours was also not followed correctly, with doses administered at 4:00 a.m., 8:30 a.m., and 9:00 p.m. Interviews with the Director of Nursing and Licensed Staff D revealed that the facility's policy required nurses to verify the right medication and dosage before administration, allowing a one-hour window before or after the scheduled time. Despite this policy, the medication was not administered as prescribed, leading to potential risks for the resident. The facility's policy on administering medications, revised in April 2019, emphasized the importance of checking the medication label three times to ensure the correct resident, medication, dosage, time, and method of administration.
Call Light System Malfunction
Penalty
Summary
The facility failed to ensure that the call light system was in good working condition for one of the residents, identified as Resident 8. This deficiency was observed during a review of the resident's records, interviews, and direct observations. Resident 8, who was admitted with diagnoses including age-related cognitive decline, COPD, and muscle weakness, had a BIMS score indicating cognitive intactness and required assistance with transfers. On a specific date, Resident 8 was found lying on the floor next to her bed, and during subsequent interviews, it was revealed that her call light had not been functioning for a long time. Another resident, Resident 6, confirmed that she would activate her own call light to assist Resident 8 when needed. During an observation, it was confirmed that Resident 8's call light did not activate, while Resident 6's call light was functional. Unlicensed Staff B verified that the call light connector in Resident 8's room was obstructed by dirt or grease, preventing a proper connection. After cleaning the connector, the call light was restored to working order. The Maintenance Director stated that daily room rounds were conducted to test call lights, but he had not received any reports about Resident 8's call light malfunctioning. The facility's policy requires that the resident call system remains functional at all times, which was not adhered to in this case.
Inaccurate MDS Completion for a Resident
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) for one of the sampled residents, leading to incomplete information necessary for developing a resident-centered care plan. The resident in question was admitted with diagnoses including unsteadiness on feet and other abnormalities of gait and mobility. The MDS dated for the resident indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, suggesting cognitive intactness. However, during an interview and concurrent record review, it was revealed that the MDS assessment for the resident was inaccurately completed, with several areas such as eating, maintaining oral and personal hygiene, showering/bathing, dressing, and footwear not assessed or lacking information. The MDS Coordinator acknowledged the inaccuracies in the MDS assessment and confirmed her responsibility for ensuring its accuracy. The facility's policy on comprehensive assessments and care delivery, revised in December 2016, outlines the process of collecting and analyzing information, choosing and initiating interventions, and monitoring results. It also specifies that the MDS should be completed within 14 days after admission. The failure to accurately complete the MDS assessment resulted in a lack of complete information necessary to meet the resident's healthcare needs.
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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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