Motion Picture And T.v. Hosp D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodland Hills, California.
- Location
- 23388 Mulholland Dr., Woodland Hills, California 91364
- CMS Provider Number
- 055034
- Inspections on file
- 22
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Motion Picture And T.v. Hosp D/p Snf during CMS and state inspections, most recent first.
A resident with dementia was admitted with home medications, including Norco and Klonopin, but staff did not inventory or document these medications on the admission belongings form or in any other log. Nursing and pharmacy reviewed the medications and sent them to the pharmacy for storage, and they were later returned to the resident’s family, yet no counts or records were maintained at any point. Leadership confirmed that it was not the facility’s practice to include home medications on the Resident Belongings and Valuables form and that no separate tracking process existed, despite written policies requiring verification, counting, and documentation of patient-supplied medications and all personal effects that may affect health and safety.
A resident with dementia and multiple chronic conditions was physically harmed when a CNA, observed by another staff member, forcefully and aggressively assisted her to the commode, violating her rights to dignity and safe care. The facility's risk management confirmed the incident as staff misconduct, and documentation showed the resident's rights to be free from abuse and to be treated with respect were not upheld.
A resident with dementia and multiple chronic conditions was subjected to rough handling by a CNA, who was witnessed forcefully assisting the resident to the commode. Despite facility policy requiring immediate suspension of employees suspected of abuse, the CNA continued to work several shifts after the incident, leaving the resident exposed to possible further abuse. The facility's abuse prevention and reporting procedures were not enforced.
A resident with dementia and multiple chronic conditions was forcefully handled by a CNA during toileting assistance, as witnessed by another CNA. The incident, which constituted misconduct, was not reported to law enforcement, the ombudsman, or the licensing agency within the required 24-hour period, resulting in a delayed investigation. The facility's policy and regulatory requirements for timely reporting were not followed.
Two residents with moderate cognitive impairment were administered psychoactive medications, including lorazepam, mirtazapine, escitalopram, and gabapentin, without documented written informed consent from themselves or their responsible parties. Nursing staff confirmed that the required consents, which should include discussion of risks and benefits, were not present in the medical records, contrary to facility policy.
The facility did not develop or implement comprehensive, person-centered care plans for multiple residents, resulting in disorganized documentation and missing critical interventions. For two residents with complex medical and cognitive needs, care plans grouped all problems and interventions together, making it difficult for staff to identify appropriate actions. In another case, a resident assessed as needing a smoking apron for safety did not have this intervention included in the care plan, increasing the risk of staff missing this requirement.
The facility failed to follow professional standards in medication administration, including administering scheduled medications outside of ordered times without proper documentation or provider approval for two residents, not checking g-tube placement and patency or flushing between medications for a resident with a feeding tube, and not rotating subcutaneous insulin injection sites for a resident as required by guidelines. These actions were inconsistent with facility policy and professional standards.
Four residents with limited ROM and mobility did not receive timely or appropriate restorative nursing interventions and quarterly PT/OT joint mobility screens as recommended by therapy staff. Orders for ambulation were not updated to reflect therapy recommendations, and there were significant delays in initiating RNA programs and completing required assessments.
Multiple deficiencies were identified, including a resident on swallow precautions left unsupervised during meals, a bottle of antiseptic left at a bedside mixed with food, exposed/frayed wires on a call light, fall mats obstructed by furniture, and an unattended medication cup left accessible to a resident with dementia. These actions and inactions by staff failed to maintain a safe environment and proper supervision, as required by facility policy.
Surveyors found that a nurse administered a discontinued topical medication to a resident without a current physician's order, and that two residents received scheduled medications outside the prescribed time without proper documentation or provider notification. Additionally, a nurse failed to follow required procedures for administering medications via a gastrostomy tube, including not checking tube placement and not flushing between medications. These actions were not in accordance with facility policies and procedures.
The facility did not ensure that residents receiving high-risk medications, including antibiotics and antiplatelet agents, were monitored for adverse effects. Two residents on antibiotics and one resident on both aspirin and clopidogrel lacked orders or documentation for monitoring side effects, as confirmed by nursing, pharmacy, and leadership staff. This omission was identified through interviews and record reviews, with staff acknowledging the absence of required monitoring.
A facility was cited for a medication error rate of 25% after an LVN administered scheduled medications to two residents outside the prescribed time without proper documentation or provider approval, and failed to flush a g-tube between medications for another resident, contrary to facility policy. The LVN also did not check g-tube placement and patency at each administration as required. These actions were confirmed through observation, interviews, and record review.
Surveyors found that a resident did not have insulin injection sites rotated as required, two residents received scheduled medications outside the prescribed time window without proper documentation or provider approval, and another resident did not receive required water flushes between medications administered via g-tube. Nursing and pharmacy leadership confirmed these actions were not in accordance with facility policy or standard practice.
Surveyors identified multiple deficiencies in food storage and preparation, including unlabeled and improperly sealed food items, inaccurate container labeling, and improper storage of produce in wet conditions. Staff personal items were also found in food storage areas, contrary to facility policy. These actions were confirmed by interviews with the DHS and DLTC, who acknowledged the failures to follow established procedures.
Two residents did not have required PT and OT discharge summaries completed after their therapy services ended, despite facility policy mandating documentation within 48 hours. Therapy staff confirmed the omissions, which resulted in incomplete medical records and lack of formal communication regarding residents' therapy discharge status and recommendations.
Staff failed to follow infection control protocols by not wearing required PPE, such as masks and gowns, when entering rooms of residents on droplet or enhanced barrier precautions, and by using permeable covers on linen carts that did not adequately protect clean linens from contamination. These actions were observed during care of residents with respiratory symptoms, wounds, or indwelling devices, and staff acknowledged not following posted precautions or facility policy.
A resident with multiple chronic conditions experienced hypoxia, and although oxygen was administered per physician order, staff failed to notify the provider and responsible party of the change in condition as required by facility policy. Documentation and interviews confirmed that neither notification nor proper record of notification occurred.
A resident with severe cognitive impairment and multiple comorbidities did not receive proper pressure injury assessment and documentation. Nursing staff incorrectly restaged a pressure injury from unstageable to stage 2, contrary to professional standards, rather than documenting it as a healing unstageable PI. This error was confirmed by RNs and the DLTC, who acknowledged that accurate wound assessment and documentation were not followed according to facility policy.
A resident with a suprapubic urinary catheter was found to have the catheter tubing not anchored to the statlock device on their thigh, despite facility policy and physician orders requiring securement. Staff confirmed that the catheter should have been anchored to prevent movement or accidental dislodgement.
A discontinued topical medication was not removed from a treatment cart, leading an LVN to continue administering it to a resident with a stage 2 pressure injury. The resident, who was dependent on staff and unable to communicate, received the medication after its order had been discontinued, as the ointment remained accessible in the cart. Facility staff confirmed that policy required immediate removal of discontinued medications, but this was not followed, resulting in the deficiency.
A resident with chronic recurrent pneumonia was prescribed azithromycin twice weekly for pneumonia prophylaxis without a stop date or clear clinical guideline. Staff, including nursing, pharmacy, and infection prevention, did not clarify the appropriateness of this prolonged antibiotic use or communicate concerns as required by facility policy, resulting in a failure to ensure proper antibiotic stewardship.
The facility failed to establish and implement policies for the use of side rails (SR) and physical restraints. Both the DON and ADM acknowledged the absence of these policies, which had the potential to cause significant harm to all 87 residents.
The facility failed to keep the call light within reach of four residents, which had the potential for delaying care and services and placing them at risk for falls and injuries. Observations revealed that the call lights were not accessible to the residents, despite their care plans indicating the need for the call light to be within reach due to high fall risk. The facility's policies and procedures were not followed in these cases.
The facility failed to ensure residents' freedom from physical restraints by not assessing the need for side rails, assessing the risk for entrapment, obtaining informed consent, or securing a physician's order. This was observed in four residents, with side rails raised and beds pushed against walls without proper documentation. Chair alarms were also used without necessary assessments or consents.
The facility failed to follow manufacturer's guidelines for pressure ulcer prevention for two residents. One resident's low air loss mattress (LALM) was not set according to weight, and Heel Protectors (HP 1) were not applied as ordered. Another resident's alternating pressure mattress (APP) was set at the firmest setting, causing discomfort. The facility lacked specific policies for the use of these specialty mattresses.
The facility failed to provide ROM services and baseline assessments for four residents, leading to missed RNA treatments and lack of initial ROM evaluations, which could impact their mobility and quality of life.
The facility failed to ensure the safe and appropriate use of side rails for three residents, leading to potential risks of entrapment and injury. Assessments for the risk of entrapment and informed consent were not conducted, and there were no physician's orders for side rail use. The DON acknowledged the need for proper assessments, consents, and physician's orders.
The facility failed to provide sufficient RNA staff to meet the needs of 70 residents with physician's orders for RNA services, leading to missed treatments and potential declines in residents' mobility and overall well-being. Staffing records and staff interviews confirmed the short-staffing issue, with some days having no RNAs available.
The facility staff failed to ensure proper food storage, preparation, and distribution, including an expired sandwich in a resident's room, serving food at low temperatures, storing moldy lemons, and improper ice machine drainage, posing risks of foodborne illness and malnutrition.
The facility failed to provide necessary OT and PT services to two residents, resulting in a lack of OT evaluations and insufficient PT sessions. Both residents expressed dissatisfaction with the limited therapy services, and staff confirmed the absence of OT and inadequate PT availability.
The facility failed to maintain an infection prevention and control program, leading to potential cross-contamination during medication administration and respiratory care. Two nurses did not perform hand hygiene before preparing medications or donning gloves, and a resident's nasal cannula was not labeled or changed weekly as required.
The facility failed to maintain a resident's dignity by not ensuring that a urinary catheter drainage bag was covered with a privacy bag. The resident had severely impaired cognition and required assistance with daily activities. Both a Licensed Vocational Nurse and the Director of Nursing confirmed that the drainage bag should have had a privacy cover, as per facility policy.
The facility failed to provide a resident and their representative with information regarding the formulation of an advance directive. The resident, who had severe cognitive impairment and was dependent on staff, did not have documentation in their medical record about an advance directive. The Director of Social Services confirmed this omission, stating that the standard procedure to ask about and provide information on advance directives was not followed.
The facility failed to develop and implement comprehensive care plans for four residents regarding the use of side rails and restraints. Observations revealed that beds were pushed against walls, side rails were raised, and alarms were used without corresponding care plans. The DON and other staff confirmed the absence of these care plans, which are required by facility policy.
The facility failed to follow physician's orders to apply thromboembolic deterrent (TED) hose for two residents. One resident with acute embolism and thrombosis was found not wearing TED hose, and the CNA was unaware of the order. Another resident with a history of venous thrombosis and embolism was found wearing regular socks instead of TED hose, and the CNA did not know if the resident ever wore them. The DON confirmed the orders and acknowledged the lack of a policy for TED hose use.
The facility failed to ensure safe transfers and medication administration by allowing a CNA to transfer a resident using a Hoyer lift without assistance and leaving a bottle of lidocaine 4% roll-on at a resident's bedside, contrary to facility policies.
The facility failed to label a bottle of valproic acid solution with an expiration date, affecting a resident with dementia and Alzheimer's disease. This oversight was confirmed by both an LVN and the DON, who acknowledged the importance of proper labeling according to the facility's policy.
The facility failed to cover the garbage container next to the hand washing station in the kitchen, which had the potential for the spread of bacteria and cross-contamination. The Director of Hospitality, Registered Dietitian, and Director of Nursing all confirmed that the garbage container should have a lid to prevent contamination.
The facility failed to maintain timely medical records for a resident when a PT Initial Evaluation dated several months prior was not documented until recently. The delay was confirmed by the PT and DON, who both acknowledged that documentation should be completed promptly to ensure accuracy.
Failure to Inventory and Document Home Medications on Admission
Penalty
Summary
The facility failed to inventory a resident’s home medications upon admission, resulting in mismanagement of those medications. The resident, who had dementia and was prescribed Norco and Klonopin, was admitted with personal belongings and home medications from an assisted living facility. The Resident Belongings/Valuables admission inventory form dated 12/11/2025 did not list any home medications, was unsigned, and noted that the resident was unable or refused to sign. Interviews with the Chief Nursing Officer and Director of Risk Management confirmed that the resident’s home medications were brought in at admission, reviewed by the admitting Nurse Practitioner, and then sent to the pharmacy, but no inventory or documentation of these medications was completed by nursing, pharmacy, or on the belongings form. The Chief Nursing Officer stated that the pharmacy evaluated the home medications to determine if any were needed temporarily and then kept them until they were returned to the resident’s daughter a few days later. The Director of Risk Management reported that the usual practice was for home medications to go to nursing and pharmacy for review and then be returned to the family, and that the facility did not keep home medications or document them on the Resident Belongings and Valuables form. The Director also confirmed there was no separate process in place to track, inventory, or document patient home medications. These practices were inconsistent with the facility’s policies, which required that medications brought in at admission be verified, counted, and documented in a log when transferred to pharmacy, and that all personal effects, including items that may affect health and safety, be recorded on the Resident Belongings and Valuables form or in the EHR. The deficient practice resulted in mismanagement of the resident’s home medications and created a high risk of lost belongings, medication omissions, and discrepancies in treatment.
Resident Rights Violated Due to Rough Handling by Staff
Penalty
Summary
A deficiency occurred when a staff member failed to uphold a resident's rights to a dignified existence and safe care environment. According to interviews and record reviews, a certified nurse assistant (CNA) was observed by another CNA forcefully assisting a resident with dementia, chronic kidney disease, multiple venous thromboembolisms, fibromyalgia, and spinal stenosis to the commode. The witness described the staff member as becoming frustrated and manhandling the resident by her armpits, then slamming her onto the commode with aggressive and excessive force. This incident resulted in physical harm to the resident. The facility's Director of Risk Management and Regulatory Affairs confirmed that the staff member's behavior was considered misconduct due to the rough handling. Review of the resident's admission agreement and the facility's resident rights documentation indicated that residents are to be free from mental and physical abuse and treated with respect. The actions of the staff member violated these documented rights, as the resident was not provided care in a manner that ensured her dignity and safety.
Failure to Enforce Abuse Prevention Policy Resulting in Resident Exposure to Alleged Perpetrator
Penalty
Summary
The facility failed to enforce its own abuse prevention and reporting policies for a resident with dementia and multiple chronic medical conditions, including VTE, CKD, fibromyalgia, and spinal stenosis. On one occasion, a CNA was witnessed by another CNA forcefully and aggressively handling the resident while assisting her to the commode, including manhandling her by the armpits and slamming her onto the commode. The incident was observed to be an act of misconduct due to rough handling, as confirmed by the Director of Risk Management and Regulatory Affairs. Despite the facility's policy requiring immediate suspension of employees suspected of abuse to protect residents, the CNA involved continued to work several shifts after the incident. The DON acknowledged that the CNA should have been suspended the same day as the incident, and that the delay left the resident exposed to potential further abuse. The facility's Code of Conduct and abuse prevention policies, which require residents to be treated with care and respect and mandate suspension of suspected employees, were not followed in this case.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident in accordance with its own policy and regulatory requirements. A certified nurse assistant (CNA) witnessed another CNA forcefully and aggressively assist a resident with dementia, chronic kidney disease, venous thromboembolism, fibromyalgia, and spinal stenosis to the commode, using excessive force and manhandling the resident. The incident occurred late at night and was not reported to the appropriate authorities within the required 24-hour timeframe. The facility's Director of Nursing acknowledged that the incident was reported late to the licensing agency, local law enforcement, and ombudsman, as the report was sent by fax several days after the event. Facility policy required a telephone report to law enforcement and written reports to the ombudsman and licensing agency within 24 hours of the incident. The delay in reporting resulted in a delayed investigation by the state agency and law enforcement. Medical assessment of the resident after the incident did not reveal any injuries or discoloration.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties were fully informed and provided with written informed consent prior to the administration of psychoactive medications. For two sampled residents, the required documentation of informed consent was not found for several prescribed psychotropic medications, including lorazepam, mirtazapine, escitalopram, and gabapentin. This omission was identified through interviews and record reviews, where staff confirmed the absence of signed consents in the residents' medical records. One resident, who had a history of depression, insomnia, and atrial fibrillation, was admitted with moderate cognitive impairment and was prescribed multiple psychoactive medications for anxiety, depression, and insomnia. Despite the facility's policy requiring written informed consent for such medications, no documentation of consent was present for any of the prescribed drugs. Staff interviews confirmed that the process of obtaining and documenting informed consent, including discussion of risks and benefits, had not been completed as required. A second resident, also with moderate cognitive impairment and diagnoses of anxiety disorder, depression, and diabetes mellitus, was prescribed escitalopram for depression and anxiety. Again, review of the medical record and interviews with nursing staff revealed that no written informed consent was obtained or documented for the use of this psychotropic medication. The facility's policy, which mandates informed consent and regular renewal every six months, was not followed in these cases, resulting in a violation of the residents' rights to make informed decisions regarding their care.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, resulting in disorganized documentation and the omission of critical interventions. For two residents with multiple medical conditions and cognitive impairments, the care plans listed all medical problems together without grouping them by specific issues, and the associated goals and interventions were not tailored to individual problems. Instead, interventions were mixed together, making it difficult for staff to identify which actions corresponded to which medical issues. Both nursing and administrative staff acknowledged that this disorganization could lead to delays in care and miscommunication among healthcare providers. In another instance, a resident who expressed a desire to smoke was assessed by the interdisciplinary team and determined to require the use of a smoking apron for safety. However, the resident's care plan did not include the intervention of wearing the apron, despite this being identified as necessary in the assessment. Staff interviews confirmed that the omission was an oversight, and that the care plan is the primary tool used to communicate required interventions to all staff. The absence of this intervention in the care plan created the potential for staff to allow the resident to smoke without the required safety equipment. The facility's own policies and procedures require that care plans be comprehensive, coordinated, and based on individual assessments, including specific goals, interventions, and review dates. In each of the cases reviewed, the care plans did not meet these requirements, as they failed to clearly communicate individualized problems and interventions, and in one case, omitted a critical safety intervention altogether.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice in several areas related to medication administration. For two residents, scheduled medications were not administered as ordered at the scheduled times. In both cases, a licensed nurse administered medications earlier than the scheduled time without proper documentation or provider authorization, and the electronic medication administration record (MAR) did not allow for accurate recording of the actual administration time. The nurse reported giving medications early based on resident preference and convenience, but did not consistently document the reason or obtain a revised order, as required by facility policy and professional standards. For another resident with a gastrostomy tube (g-tube), the nurse failed to check the tube's placement and patency before administering medications, and did not flush the tube with water between each medication as required by facility policy. The nurse stated that she only checked for patency once per shift and did not flush between medications because there was no specific physician order to do so. However, facility policy and interviews with supervisory staff confirmed that placement and patency should be checked before every medication administration and that flushing between medications is necessary to prevent mixing and ensure proper delivery. Additionally, for a resident receiving subcutaneous insulin, the facility did not rotate injection sites as required by professional standards and the manufacturer's guidelines. Review of administration records showed repeated use of the same injection sites over multiple days. Nursing staff and facility leadership acknowledged that injection sites should have been rotated to prevent adverse effects and ensure proper absorption, but this was not done according to the established protocols.
Failure to Provide Timely ROM Interventions and Assessments
Penalty
Summary
The facility failed to provide appropriate treatments and services to prevent a decline in joint range of motion (ROM) and mobility for four residents with limited ROM and mobility. For one resident with hemiplegia and contracture of the left hand, the Restorative Nursing Aide (RNA) program order for ambulation was not updated to reflect the Physical Therapy (PT) recommendation to use a platform walker for stability after PT discharge. Instead, the resident continued to ambulate with a front-wheeled walker, contrary to PT's recommendation. Additionally, this resident did not receive the required quarterly PT and Occupational Therapy (OT) joint mobility screens (JMS) as scheduled. Another resident with dementia and lower extremity ROM impairment did not receive timely RNA treatments for ambulation after PT recommended RNA upon discharge. There was a delay of about three months before the RNA order was implemented. This resident also missed a quarterly PT JMS, which was not completed as required. Interviews with staff confirmed that RNA programs should be initiated immediately after PT or OT discharge and that quarterly JMS are necessary to monitor for changes in ROM and function. Two additional residents, one with multiple sclerosis and functional quadriplegia and another with congestive heart failure and polyarthritis, did not receive their scheduled quarterly PT and OT JMS. Staff interviews revealed that these screenings are intended to monitor joint mobility and identify any changes or declines. The facility lacked a policy and procedure for PT and OT joint mobility screening or monitoring ROM, contributing to the missed assessments.
Failure to Prevent Accident Hazards and Ensure Resident Supervision
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for multiple residents, as evidenced by several observed deficiencies. One resident on swallow precautions, with a history of stroke and recurrent pneumonia, was left unsupervised while eating breakfast and was not positioned at the required 90-degree angle. The assigned staff member admitted to leaving the resident alone during meals, despite clear orders and posted signage requiring supervision and specific positioning to prevent aspiration or choking. Another resident with cognitive deficits and a diabetic foot ulcer had a bottle of Daikin's solution, a strong antiseptic, left at the bedside mixed with food items. Facility staff acknowledged that medications should not be left at the bedside due to the risk of accidental ingestion. Additionally, a resident with severe cognitive impairment and high fall risk was found to have a call light cord with exposed/frayed wires and fall mats with furniture and equipment placed on top, compromising both electrical safety and the effectiveness of the fall mats. Similar issues were observed with another resident, where overbed tables were placed on top of bilateral floor mats, increasing the risk of injury and reducing the protective function of the mats. A further deficiency was noted when a resident with dementia and impaired safety judgment had an unattended medication cup containing ointment left at the bedside, accessible for self-administration. Multiple staff members entered the room without removing the ointment, and it remained on the nightstand for an extended period. Staff interviews confirmed that medications should not be left unattended in resident rooms, especially in units where residents have dementia and impaired safety awareness. Facility policies and procedures reviewed during the survey supported the need for a hazard-free environment and proper medication administration practices, which were not followed in these instances.
Medication Administration and Pharmaceutical Service Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies in the administration of pharmaceutical services and medication management for several residents. One incident involved a nurse administering mupirocin ointment to a resident with a stage two sacral pressure injury without a current physician's order. The nurse had continued to apply the discontinued medication, which remained in the treatment cart, for several days, believing there was still an active order. Both the nurse and other staff acknowledged that the medication should have been removed from the cart after discontinuation, and that medication administration should always be based on an active physician's order, as per facility policy. In another instance, two residents did not receive their scheduled medications at the prescribed times. A nurse administered medications earlier than the scheduled time, outside the one-hour window allowed by facility policy, due to the residents' preferences and convenience. The nurse did not document the reason for the early administration or obtain a revised order from the provider to reflect the change in timing. The facility's electronic medication administration record (eMAR) system also did not allow documentation of the actual time of administration outside the scheduled window, leading to further deviation from policy. Additionally, a nurse failed to follow proper procedures for administering medications via a gastrostomy tube for another resident. The nurse did not check the tube's placement and patency before administering medications and did not flush the tube with water between medications. These actions were not in accordance with the facility's medication administration policies and procedures, which require verification of tube placement and flushing to ensure safe and effective medication delivery.
Failure to Monitor for Adverse Effects of High-Risk Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs by not providing appropriate monitoring for adverse effects associated with certain high-risk medications. For two residents receiving antibiotics, there was no documented monitoring for adverse effects. One resident was prescribed azithromycin for pneumonia prophylaxis without an order or documentation for monitoring potential side effects, despite the medication's known risks, especially in elderly patients. Interviews with nursing and pharmacy staff confirmed the absence of such monitoring and emphasized its importance for timely intervention and prevention of complications, including antibiotic resistance. Another resident was prescribed amoxicillin as a PRN order for dental procedure prophylaxis, but the order lacked instructions for monitoring adverse effects. The medication was only administered once, but staff and a nurse practitioner noted that the PRN order increased the risk of medication errors and that monitoring for adverse effects was not in place. Facility leadership acknowledged that the order should have been written as a one-time dose and that monitoring for adverse effects was necessary to ensure safe use of the antibiotic. A third resident was prescribed both aspirin and clopidogrel for stroke prophylaxis, but there was no order or documentation for monitoring adverse effects such as bleeding. Nursing staff and facility leadership confirmed the lack of monitoring and highlighted the importance of such oversight to prevent and address potential adverse reactions. Product information for these medications, provided by the facility, listed significant risks such as hemorrhage and other side effects, underscoring the need for monitoring that was not implemented.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with seven medication errors identified out of 28 opportunities, resulting in a 25% error rate. For two residents, a licensed vocational nurse (LVN) administered scheduled 9 a.m. medications earlier than the prescribed time without proper documentation or provider authorization. The LVN stated that the residents preferred to receive their medications earlier, and although the nurse practitioner or physician was reportedly notified, there was no documented order to change the scheduled administration time. Facility policy and interviews with the Director of Pharmacy and Director of Long-Term Care confirmed that medications should be administered within one hour before or after the scheduled time, and any deviations require provider approval and documentation. In another instance, the same LVN failed to follow facility policy for administering medications via gastrostomy tube (g-tube) for a resident with epilepsy, muscle spasm, neuralgia, and neuritis. The LVN did not flush the g-tube with water between administering different medications, contrary to the facility's policy, which requires flushing with 15-30 ml of water between each medication to prevent mixing and ensure tube patency. The LVN stated she followed the physician's order to flush before and after medication administration but did not flush between medications due to the absence of a specific order. Interviews with facility leadership confirmed that the standard of practice and facility policy require flushing between medications, and the LVN acknowledged not following this procedure. Additionally, the LVN did not check the g-tube for placement and patency at every scheduled medication administration, as required by facility policy. Instead, she checked for patency only once per shift, based on instructions she believed were provided by her supervisor. However, facility leadership clarified that the policy is to check placement, patency, and residual before every medication administration. The failure to adhere to these procedures was confirmed through interviews, record reviews, and direct observation, and was not in accordance with the facility's written policies and procedures for safe medication administration.
Medication Administration Errors and Failure to Follow Protocols
Penalty
Summary
Surveyors identified multiple deficiencies related to medication administration for several residents. One resident receiving insulin (liraglutide/Victoza) did not have injection sites rotated as required by standards of practice and the manufacturer's guidelines. Documentation showed repeated use of the same injection sites over several months, and nursing staff confirmed that site rotation was not performed. This failure was acknowledged by both nursing staff and facility leadership, who stated that not rotating sites can affect medication absorption and is not in accordance with accepted practice. Two other residents were found to have received scheduled oral medications outside of the prescribed administration window. Nursing staff administered medications earlier than the scheduled time, citing resident preference and convenience, but did not document provider approval or the reason for the deviation. Facility policy and interviews with pharmacy and nursing leadership confirmed that medications should be given within a one-hour window before or after the scheduled time, and any deviations should be communicated to and approved by the provider, with documentation in the medical record. The electronic medication administration record (eMAR) system did not allow documentation of the actual administration time outside the allowed window, and staff reported giving medications early on multiple occasions without proper documentation or provider notification. Additionally, a resident receiving medications via gastrostomy tube (g-tube) did not have water flushes administered between medications, contrary to facility policy and standard practice. The nurse administered all medications consecutively, flushing only before and after the medication pass, and stated that she followed the physician's order, which did not specify flushing between medications. Facility policy, as well as statements from nursing and pharmacy leadership, required flushing with water between each medication to prevent mixing and ensure tube patency. The nurse also did not consistently check tube placement and patency as required by policy.
Deficient Food Storage and Preparation Practices
Penalty
Summary
Surveyors observed multiple failures in food storage and preparation practices within the facility's kitchen. A disposable cup of coffee belonging to a kitchen staff member was found on top of a metal cart outside the dry food storage area, despite facility policy prohibiting personal or staff food items in the kitchen to prevent cross contamination. Several food items in the dry storage area, including boxes of dried noodles, a bottle of instant coffee, and a box of wonton chips, were found open and not labeled with an open date. Additionally, the wonton chips were stored in an unsealed plastic bag. A container labeled as containing black-eyed peas was found to actually contain brown short grain, which appeared to be brown rice, and red potatoes were observed stored in a wet bin rather than a dry container as required by policy. Interviews with the Director of Hospitality Services and the Director of Long-Term Care confirmed that these practices were not in accordance with facility policy or professional standards. Both directors acknowledged that all opened food items should be labeled with an open date, containers should be labeled accurately, and produce should be stored in dry containers to prevent contamination. The facility's policy and the Food Code 2022 were reviewed, both of which require proper labeling, sealing, and storage of food items to maintain safety and prevent contamination.
Failure to Complete Timely Therapy Discharge Summaries
Penalty
Summary
The facility failed to maintain timely and accurate medical records for two residents by not completing required discharge summaries for physical therapy (PT) and occupational therapy (OT) services. For one resident with diagnoses including congestive heart failure and polyarthritis, the last PT and OT treatment notes were completed in early January, but no discharge summaries were documented after therapy services ended. Interviews with the therapy manager confirmed that discharge summaries should have been completed at the time of discharge, as they provide essential information on the resident's progress, current level of function, and recommendations for ongoing care. Another resident, admitted with conditions such as anoxic brain damage, hemiplegia, and monoplegia, also did not have a PT discharge summary completed after the last PT treatment. The physical therapist confirmed that the resident was discharged from PT, but the required summary was not documented. The absence of these summaries meant that other staff were not formally informed of the residents' therapy discharge status or the recommendations for their continued care. Facility policy required all documentation to be completed within 48 hours of service provided or attempted. The failure to complete these discharge summaries for both residents was identified through record review and staff interviews, demonstrating a lack of adherence to the facility's documentation standards and professional requirements for maintaining accurate and timely medical records.
Failure to Adhere to Infection Control Protocols and Proper Linen Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to required personal protective equipment (PPE) protocols and improper linen storage. In one instance, an Activities Assistant entered the room of a resident on droplet precautions without donning a mask or any PPE, despite clear signage at the door indicating the need for a surgical-grade mask. The staff member admitted to not reading the sign before entering and was unaware of the specific requirements, even after reviewing the sign post-incident. The resident in question had respiratory symptoms and was under physician-ordered droplet precautions. In two other cases, Certified Nursing Assistants and another staff member failed to wear isolation gowns and gloves while performing high-contact activities, such as transferring, oral hygiene, and other ADL care, for residents on Enhanced Barrier Precautions (EBP) due to the presence of wounds or indwelling devices like a g-tube. Despite signage and facility policy requiring gowns and gloves for these activities, staff either forgot or neglected to follow the protocol. Interviews confirmed that staff were aware of the requirements but did not comply during the observed care activities. Additionally, the facility was observed to be using linen cart covers made of loosely woven, permeable material, which staff and supervisors acknowledged would not adequately protect clean linens from environmental contaminants. The facility's own policy required clean linen to be transported in covered carts to prevent contamination, but the covers in use allowed air and liquids to pass through, potentially exposing linens to bacteria and viruses.
Failure to Notify Provider and Responsible Party After Resident's Hypoxia Episode
Penalty
Summary
A deficiency occurred when the facility failed to notify both the physician and the resident's responsible party (RP) after a resident experienced an episode of hypoxia. The resident, who had diagnoses including dementia, major depressive disorder, and Parkinson's disease, was admitted with severely impaired cognition and required substantial to total assistance with activities of daily living. The resident had an existing physician's order for oxygen via nasal cannula as needed for hypoxia. On the date of the incident, nursing staff assessed the resident for hypoxia, noting an oxygen saturation of 83-85% on room air and a respiratory rate of 30 per minute. Oxygen was applied and titrated to 1 L/min, resulting in an improved oxygen saturation of 93%. However, the nursing documentation did not indicate that the medical provider or the resident's RP were notified of this change in condition. Interviews with the registered nurse and the Director of Long-Term Care confirmed that neither the provider nor the RP were notified, and there was no documentation of such notification in the resident's records. Both staff members acknowledged that facility policy requires notification of the provider and RP for any change in condition, and that this was not followed in this instance. The facility's policy specifically states that the provider and responsible party must be notified of significant changes in a resident's status, and documentation of the notification must be maintained.
Failure to Accurately Assess and Document Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards of practice to prevent and manage a pressure injury (PI). Specifically, the nursing staff did not perform an accurate assessment of the resident's pressure injury on the right buttock. The wound was initially documented as a stage 2 PI, later as an unstageable PI, and then incorrectly reclassified as a stage 2 PI, which constitutes reverse staging—a practice not permitted by professional standards. Multiple registered nurses and the Director of Long-Term Care confirmed during interviews that the wound should have been documented as a healing unstageable PI rather than being restaged to a lower classification. The resident involved had a history of dementia, major depressive disorder, and mobility abnormalities, and required significant assistance with activities of daily living, including total assistance with toileting, hygiene, bathing, and transfers. The resident's clinical records indicated severe cognitive impairment but retained the ability to communicate needs. The wound care assessments were completed weekly by registered nurses and documented in the facility's electronic health record, but the documentation failed to accurately reflect the wound's progression and stage. Facility policy required accurate and complete documentation of pressure injuries, including proper staging and ongoing evaluation. The failure to accurately assess and document the pressure injury as healing unstageable, rather than incorrectly restaging it as stage 2, meant that the resident was at risk for inappropriate treatment and potential worsening of the wound. This deficiency was confirmed through record review and staff interviews, which acknowledged the error and the importance of proper wound assessment and documentation.
Failure to Anchor Suprapubic Catheter to Statlock
Penalty
Summary
A deficiency was identified when a resident with a suprapubic urinary catheter was observed to have the catheter tubing not anchored to the statlock device on their right thigh. The statlock, which is intended to secure the catheter and prevent movement or accidental dislodgement, was present but not utilized as required. This observation was confirmed by both a Licensed Vocational Nurse and the Director of Long Term Care, who stated that all urinary catheters should be anchored to prevent movement and potential complications. The resident involved had a history of unspecified dementia, hypertension, and the presence of a suprapubic catheter, and required varying levels of assistance with activities of daily living. Physician orders and facility policy both specified that indwelling catheters should be properly secured after insertion to minimize movement. Despite these directives, the catheter was not anchored, as observed during the survey, and this was acknowledged by facility staff during interviews.
Discontinued Medication Not Removed, Resulting in Continued Administration
Penalty
Summary
A deficiency occurred when a discontinued medication, mupirocin ointment, was not removed from a treatment cart after the physician's order to discontinue it. Despite the order being discontinued, the ointment remained accessible in the cart, and a Licensed Vocational Nurse (LVN) continued to administer it to a resident during wound care. The LVN stated that she routinely applied the mupirocin to the resident's pressure injury, unaware that the order had been discontinued, as the medication was still present in the cart. The resident involved had a history of neurocognitive disorder with Lewy bodies and a stage two pressure injury on the sacral region. The resident was dependent on staff for all activities of daily living and was rarely able to communicate or understand others. The care plan for the resident included specific wound care instructions, and the physician's orders had clearly discontinued the use of mupirocin prior to the observed administrations. Interviews with nursing staff and the Director of Long Term Care confirmed that facility policy required discontinued medications to be removed from nursing stations immediately to prevent inadvertent administration. However, the discontinued mupirocin was not removed, resulting in its continued use on the resident. The failure to remove the medication from the cart and the subsequent administration of a discontinued drug constituted a breach of accepted medication storage and administration practices.
Failure to Clarify Prolonged Azithromycin Use for Pneumonia Prophylaxis
Penalty
Summary
The facility failed to reduce the risk of adverse events and the development of antibiotic-resistant organisms by not clarifying the appropriate indication for the use of azithromycin as a prophylaxis for pneumonia in a resident with chronic recurrent pneumonia. The resident was admitted with multiple medical conditions, including dyslipidemia, chronic recurrent pneumonia, and atrial fibrillation, and had an active order for azithromycin 250 mg twice weekly for pneumonia prophylaxis without an end date. The order was continued per the primary medical doctor, and the plan of care reflected this ongoing use, but there was no documented clarification of the clinical guideline supporting this prolonged prophylactic use. Interviews and record reviews revealed that the nursing and pharmacy staff were aware of the order but did not question the appropriateness of azithromycin for pneumonia prophylaxis or the lack of a stop date. The registered nurse confirmed the order and its indication, stating that education had been provided regarding the need for stop dates and appropriate indications for antibiotics. The nurse practitioner noted that such use of azithromycin was atypical and was unable to identify a clinical practice guideline supporting it. The director of pharmacy acknowledged receiving the order but did not discuss it with the prescriber or the infection preventionist, and the issue was not brought to the Pharmacy and Therapeutics committee for peer review. The infection preventionist stated that the antibiotic stewardship program relies on communication from the pharmacist when new antibiotics are prescribed, but she was not notified when antibiotics were used for prophylaxis. She indicated that, had she been notified, she would have sought clarification from the prescriber, as azithromycin is generally used for prophylaxis in cases of bronchitis or COPD, not pneumonia. The facility's policy required the pharmacist to communicate new antibiotic orders to the infection control nurse, including the diagnosis and duration, but this process was not followed in this case, resulting in a failure to ensure the appropriateness of the antibiotic order.
Failure to Implement Policies for Side Rails and Restraints
Penalty
Summary
The facility failed to establish and implement policies and procedures regarding the use of side rails (SR) and physical restraints. During an interview and record review, the Director of Nursing (DON) admitted that the facility did not have a policy for SRs or restraints, as they considered themselves a restraint-free facility. The DON emphasized the importance of having policies to guide the facility based on the standard of care. The Administrator (ADM) also acknowledged the lack of a specific policy for restraints and stated that it was her responsibility to ensure such policies were in place. The ADM mentioned that the SR policy should include an assessment for SR usage and informed consent for any SRs used in the facility. The facility's existing policy and procedure for policy review and approval, last reviewed in April 2023, outlined a standardized process for developing, reviewing, revising, approving, implementing, and maintaining facility policies. However, this process was not followed for SRs and restraints. The lack of these policies had the potential to result in psychosocial harm, decline in physical functioning, physical harm from entrapment, and death of residents, affecting all 87 residents residing in the facility.
Failure to Keep Call Lights Within Reach
Penalty
Summary
The facility failed to keep the call light within reach of four out of five sampled residents, which had the potential for delaying care and services requested by the residents and placing them at risk for falls and injuries. Resident 77, who was admitted with diagnoses including nontraumatic subdural hemorrhage, seizures, and dementia, was observed with the call light on top of the bed while sitting on a chair away from the bed. The CNA confirmed that the call light was not within reach, which could prevent the resident from calling for help and increase the risk of falls. The resident's care plan specifically indicated the need for the call light to be within reach due to high fall risk, but this intervention was not followed during the observation. Resident 56, diagnosed with Alzheimer's disease, dementia, and glaucoma, was also found with the call light on top of the bed while sitting on a chair away from the bed. The CNA acknowledged that the call light was not within reach and should be accessible to prevent falls. The resident's care plan included an intervention to keep the call light within reach due to high fall risk, but this was not adhered to during the observation. Similarly, Resident 70, with diagnoses including Alzheimer's disease and dementia, was observed with the call light clipped on a folded blanket at the foot of the bed, out of reach. The CNA confirmed that the resident would not be able to reach the call light, which could result in the resident not being able to call for help and increase the risk of falls. Resident 12, who had hemiplegia and hemiparesis following a stroke, was found with the call light tied to the left upper side rail and dangling toward the floor, making it inaccessible. The resident stated she could not use her left arm and could not reach the call light. The CNA confirmed that the call light should have been placed on the resident's right side, where it would be accessible. The DON also acknowledged that the call light should have been within reach and that the facility's policy was not followed. The facility's policies and procedures indicated the importance of keeping the call light within reach to ensure patient safety and the ability to call for help when needed, but these were not followed in the observed cases.
Failure to Ensure Residents' Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, specifically regarding the use of physical restraints. For four sampled residents, the facility did not assess the need for side rails, assess the risk for entrapment, obtain informed consent, or secure a physician's order before using side rails and positioning beds against walls. This was observed in Residents 8, 77, 56, and 70. For instance, Resident 8, who had advanced dementia and a history of falls, was found with side rails raised and the bed pushed against a dresser without proper assessments or consent. The Director of Nursing (DON) confirmed that no assessments or consents were documented for these actions, which restricted the resident's movement and posed risks of entrapment and injury. Additionally, the facility used chair alarms for Residents 77 and 56 without assessing the need, obtaining a physician's order, or securing informed consent. Resident 77's bed was pushed against the wall with both upper side rails up, and a chair alarm was in place, all without proper documentation or consent. Similarly, Resident 56's bed was pushed against the wall, and a chair alarm was used without the necessary assessments or consents. The DON and other staff members acknowledged that these interventions were considered nursing interventions and did not require a physician's order, which was incorrect. The facility's lack of a specific policy for restraints and the misunderstanding of what constitutes a restraint led to these deficiencies. The DON and Administrator admitted that they were unaware of the regulations regarding side rail use and the need for assessments and consents. The facility's policy indicated that residents have the right to be free from restraints, but this was not adhered to in practice. The DON acknowledged the risks associated with the improper use of side rails and bed positioning, including restriction of movement, entrapment, and potential physical harm.
Failure to Follow Manufacturer's Guidelines for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers for two residents. For Resident 58, the facility did not set the low air loss mattress (LALM) according to the resident's weight and failed to apply Heel Protectors (HP 1) on both lower extremities as ordered. During an observation, it was noted that the HP 1 was only applied to the right lower extremity, and the LALM was set based on resident comfort rather than the manufacturer's guidelines. The Central Supply Staff (CSS) admitted to not following the manufacturer's guidelines and did not inform the Administrator about the issues with the company's responsiveness. The Director of Nursing (DON) confirmed the lack of a policy on the use of LALM and emphasized the importance of following the manufacturer's guidelines to prevent skin breakdown effectively. For Resident 45, the facility did not set the alternating pressure mattress (APP) according to the user manual. The APP mattress was observed to be set at the firmest setting, which the resident found uncomfortable and reported mild low back pain. The Certified Nursing Assistant (CNA) and Licensed Vocational Nurse (LVN) confirmed that the mattress settings were based on resident comfort rather than the manufacturer's guidelines. The DON reiterated the importance of following the manufacturer's guidelines, especially since the facility lacked a policy on the use of specialty mattresses. The facility's policies and procedures on pressure injury monitoring and the use of specialty beds were reviewed. The policies indicated the need for a comprehensive evaluation and treatment for residents with pressure injuries and the implementation of specialty beds as ordered. However, the facility did not have specific policies for the use of LALM and APP mattresses, leading to inconsistent practices and potential risks for the residents involved.
Failure to Provide ROM Services and Baseline Assessments
Penalty
Summary
The facility failed to provide services and treatments to monitor and maintain joint range of motion (ROM) for four of five sampled residents. Specifically, the facility did not provide Restorative Nursing Aide (RNA) program treatments as ordered for two residents and did not conduct baseline upper extremity ROM assessments for two other residents upon admission. These deficiencies had the potential to cause a decline in ROM, mobility, and overall quality of life for the affected residents. Resident 2, who had diagnoses including Alzheimer's disease and abnormalities of gait and mobility, had orders for RNA for ambulation with a two-wheeled walker three to five days a week. However, the resident missed several RNA treatments over a three-month period. Similarly, Resident 12, who had hemiplegia and hemiparesis following a cerebral infarction, also missed multiple RNA treatments despite having orders for passive and active ROM exercises and the use of a knee splint. Additionally, the facility failed to provide baseline upper extremity ROM assessments for Residents 45 and 63 upon admission. Both residents had significant medical conditions that warranted such assessments, but due to the unavailability of an Occupational Therapist (OT), these evaluations were not completed. This lack of baseline assessment made it difficult for the facility to monitor and compare any changes in the residents' ROM over time.
Failure to Ensure Safe and Appropriate Use of Side Rails
Penalty
Summary
The facility failed to ensure the safe and appropriate use of side rails for three residents, leading to potential risks of entrapment and injury. For Resident 8, the facility did not conduct an assessment for the risk of entrapment or obtain informed consent before using side rails. The resident, who had advanced dementia and a history of falls, was observed with bilateral side rails raised and the bed positioned against a wall, restricting mobility and increasing the risk of entrapment. Interviews with staff and family confirmed that no assessment or informed consent was documented, and the facility lacked a policy on side rail use. Similarly, Resident 77, who had dementia and was at high risk for falls, was found with the bed pushed against the wall and both upper side rails raised. There was no physician's order for the use of side rails, and the staff confirmed that the side rails were used to prevent falls without conducting a risk assessment or obtaining informed consent. The DON acknowledged the need for assessments and consents for side rail use and the requirement for a physician's order. Resident 70, diagnosed with Alzheimer's disease and dementia, was also found with the bed pushed against the wall and both upper side rails raised. The resident's care plan indicated a high risk for falls, but there was no physician's order for side rail use. Staff confirmed that the side rails were used to prevent falls without conducting a risk assessment or obtaining informed consent. The DON reiterated the importance of assessing the risk of injury from entrapment and obtaining consent for side rail use.
Inadequate RNA Staffing
Penalty
Summary
The facility failed to provide adequate and sufficient nursing staff to deliver care for residents requiring Restorative Nursing Aide (RNA) services. This deficiency had the potential to affect 70 residents with physician's orders for RNA services, which included treatments such as range of motion (ROM) exercises, application of splints or braces, ambulation, strengthening exercises, and transfers. The review of the facility's nurse staffing hours from January to April 2024 revealed inconsistent RNA staffing, with some days having no RNAs available, thereby failing to meet the residents' needs as ordered by their physicians. Interviews with staff, including RNAs, Nursing Supervisors, and the Director of Nursing (DON), confirmed the short-staffing issue. The DON acknowledged that the facility was aware of the insufficient RNA staffing and that residents were not receiving their RNA treatments 3 to 5 times a week as ordered. The DON also mentioned that RNAs were sometimes reassigned to work as CNAs due to CNA staffing shortages, further impacting the delivery of RNA treatments. The RNA supervisor and other staff members echoed these concerns, stating that the current RNA staff was not enough to meet the residents' needs, leading to missed treatments and potential declines in residents' mobility and overall well-being. The facility's policy on the Restorative Nursing Program, dated June 2023, indicated that RNA activities should be performed 3 to 5 times a week as ordered. However, the facility's staffing records and staff interviews revealed that this standard was not being met. The Performance Improvement Plan required a Registered Nurse to review the ROM exercises with the RNAs monthly to ensure appropriateness and delivery, but the staffing shortages hindered the consistent implementation of this plan. Consequently, the residents with RNA orders were at risk of deconditioning and worsening contractures due to the lack of adequate RNA services.
Deficiencies in Food Storage, Preparation, and Distribution
Penalty
Summary
The facility staff failed to ensure proper storage, preparation, and distribution of food in accordance with professional standards for food service safety. In one instance, a sandwich labeled with a use-by date was found in a resident's room two days past the expiration date. The Assistant Activities Coordinator removed the sandwich, and the Licensed Vocational Nurse acknowledged that the expired sandwich should not have been in the resident's room as it could have led to food poisoning. The Director of Nursing confirmed that the facility's policy on food storage was not followed, posing a potential risk to the resident's health. Another deficiency was observed in the serving temperature of food. Two residents reported that their food was rarely delivered warm, which was confirmed by the Trayline Manager who measured the temperature of a bowl of soup at 128 degrees Fahrenheit, below the required 135 degrees. The Registered Dietician and the Director of Nursing acknowledged that serving food at low temperatures could lead to bacterial growth and decreased palatability, potentially causing malnutrition and foodborne illness. Additionally, a box of moldy lemons was found in the walk-in refrigerator, which should have been discarded to prevent the spread of mold. The Director of Hospitality and the Registered Dietician confirmed that moldy foods should not be stored or served. Furthermore, the kitchen ice machine's drainpipe was found touching the drain grate, lacking the required air gap to prevent backflow and cross-contamination. The Director of Hospitality and the Registered Dietician confirmed that this setup could lead to contamination of the ice, posing a risk of foodborne illness to residents.
Failure to Provide Adequate Rehabilitative Therapy Services
Penalty
Summary
The facility failed to provide necessary rehabilitative therapy services, including occupational therapy (OT) and physical therapy (PT), to two of five sampled residents. The facility did not provide OT services to any residents from October 7, 2023, to the present. Additionally, the facility did not conduct OT evaluations for Residents 45 and 63 upon their admission, which is part of the facility's standard of care. This failure prevented the establishment of a baseline for residents' range of motion (ROM) and their ability to perform activities of daily living (ADLs). The absence of OT services was confirmed by multiple staff members, including the Physical Therapist (PT 1), the Administrator (ADM), and the Nurse Practitioner (NP 1), who all acknowledged that there had been no OT available since October 2023. Resident 45, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, did not receive an OT evaluation or services. The resident required substantial assistance with various ADLs and had no functional limitations in ROM according to the Minimum Data Set (MDS). Despite the need for OT services to address these issues, the resident did not receive any OT evaluation or treatment. Similarly, Resident 63, who was admitted with diagnoses including morbid obesity and chronic obstructive pulmonary disease, also did not receive an OT evaluation or services. The resident required substantial assistance with lower body dressing, toileting, and chair transfers, but no OT evaluation was conducted to establish a baseline for ROM and ADLs. The facility also failed to provide adequate PT services to meet the care plans and goals for Residents 45 and 63. Resident 45's PT sessions were limited to 15 minutes once a week, which was insufficient to meet the resident's rehabilitation goals. The PT 1 confirmed that he was only available for two hours a day, four days a week, and had to divide his time among multiple units, leaving insufficient time for SNF residents. Resident 63 also received minimal PT services, with sessions lasting less than 30 minutes and occurring only once or twice a week. Both residents expressed dissatisfaction with the limited PT services, stating that they were not making progress toward their rehabilitation goals. The ADM and Nurse Supervisors acknowledged the performance issues with the contracted PT services, confirming that the residents needed more PT than was being provided.
Infection Control Deficiencies During Medication Administration and Respiratory Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to potential cross-contamination during medication administration and respiratory care. Licensed Vocational Nurse 3 (LVN 3) did not perform hand hygiene before preparing medications for Resident 2, who had multiple diagnoses including Alzheimer's disease, COPD, and type 2 diabetes mellitus. LVN 3 admitted to not performing hand hygiene, acknowledging the risk of cross-contamination and potential illness for the resident. Similarly, LVN 4 did not perform hand hygiene before donning gloves and administering eye drops to Resident 87, who had severe cognitive impairment and diagnoses including Parkinson's disease and mild intermittent asthma. LVN 4 also failed to doff gloves before leaving the resident's room to retrieve a tissue box, further increasing the risk of cross-contamination. LVN 4 admitted to the oversight and recognized the potential for bacterial introduction to the resident. Additionally, the facility did not ensure that Resident 38's nasal cannula was labeled and dated within the last seven days. Resident 38, who had diagnoses including diastolic heart failure and COPD, reported that the oxygen tubing was not changed as frequently as desired. Observations confirmed that the nasal cannula was not labeled, and staff admitted that the tubing should be changed weekly to prevent bacterial growth and potential respiratory infections. The Director of Nursing confirmed that the facility's policy was not followed, acknowledging the risk of respiratory infection due to the oversight.
Failure to Maintain Resident Dignity by Not Covering Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect by not ensuring that a urinary catheter drainage bag was covered with a privacy bag. This deficiency was observed during a random observation of a resident who had been admitted with diagnoses including neuromuscular dysfunction of the bladder, spinal stenosis, and benign prostatic hyperplasia. The resident had severely impaired cognition and required varying levels of assistance with activities of daily living. The urinary catheter drainage bag was visible from the doorway and did not have a privacy cover, which was against the facility's policy and procedure for catheter care. During the observation, a Licensed Vocational Nurse confirmed that the drainage bag should have had a privacy cover to preserve the resident's dignity and self-worth. The Director of Nursing also stated that urinary catheter drainage bags should have privacy covers, especially when facing the door. The facility's policy, last reviewed in February 2023, indicated that all Foley catheter drainage bags must have a dignity bag to ensure privacy for the patient.
Failure to Provide Information on Advance Directives
Penalty
Summary
The facility failed to provide Resident 83 and their representative with information regarding the formulation of an advance directive. Resident 83, who was admitted on 6/28/2023, had severe cognitive impairment and was dependent on staff for activities of daily living. The resident's medical record did not contain documentation indicating whether the resident or their representative had been asked about an advance directive or provided with information on creating one. The Director of Social Services (DSS) confirmed this omission during a review of the resident's medical record on 4/4/2024. The DSS stated that it is standard procedure to ask residents or their responsible persons about advance directives upon admission and to provide educational materials if needed. However, this procedure was not followed in the case of Resident 83, who was non-verbal and had their husband as the responsible person. The facility's policy and procedure on advance directives, last reviewed on 10/18/2023, mandates that each adult patient or their responsible party should receive a pamphlet on medical treatment decisions and be asked about existing advance directives upon admission. The policy also requires documentation of any advance directive in the resident's medical record. The DSS acknowledged that failing to provide this information could result in the facility not knowing how to honor the resident's wishes during end-of-life care. This deficiency had the potential to impact the resident's end-of-life care decisions, as neither the resident nor their representative were informed about their rights to formulate an advance directive.
Failure to Develop Comprehensive Care Plans for Restraint Use
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, specifically regarding the use of side rails and restraints. Resident 8, who had Alzheimer's disease and a history of falls, was observed with bilateral side rails raised and the bed placed against a built-in dresser wall cabinet, restricting the resident's ability to exit the bed. The facility did not have a care plan addressing these restraints, and the Director of Nursing (DON) confirmed that the bed placement and side rails constituted a restraint. The Minimum Data Set Coordinator (MDSC) also confirmed the absence of care plans for these restraints. Resident 77, who had dementia and a history of seizures, was observed with the bed pushed against the wall, both upper side rails up, and a chair alarm in place. The Certified Nursing Assistant/Restorative Nursing Aide (CNA/RNA) stated these measures were for fall prevention, but there was no care plan addressing the use of these restraints. Similarly, Resident 56, who had Alzheimer's and required substantial assistance for mobility, was observed with the bed against the wall and a chair alarm, but no care plan was in place for these restraints. The Nursing Supervisor (NS) confirmed the absence of care plans, considering these measures as nursing interventions rather than restraints. Resident 70, who had Alzheimer's and moderately impaired vision, was observed with the bed pushed against the wall, both upper side rails up, and an overbed table placed on the right lower side of the bed. The Certified Nursing Assistant (CNA) stated these measures were to prevent falls, but there was no care plan addressing the use of these restraints. The Nurse Informaticist (NI) and the DON confirmed the absence of care plans for these restraints, emphasizing the importance of individualized care plans to address resident problems and implement appropriate interventions. The facility's policy required comprehensive care plans based on resident assessments and individual needs, but this was not followed for the use of restraints in these cases.
Failure to Apply TED Hose as Ordered
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice by not following the physician's order to apply thromboembolic deterrent (TED) hose for two residents. Resident 77, who was admitted with diagnoses including acute embolism and thrombosis, had a physician's order for TED hose to be applied every twelve hours. However, during an observation, the resident was found not wearing the TED hose, and the Certified Nursing Assistant (CNA) was unaware of the order. The Nursing Supervisor confirmed the order but did not know why the TED hose was not applied. Similarly, Resident 56, admitted with a history of venous thrombosis and embolism, had a physician's order for TED hose to be applied twice a day. During an observation, the resident was found wearing regular socks instead of the TED hose, and the CNA did not know if the resident ever wore the TED hose. The Director of Nursing (DON) confirmed that staff should apply the TED hose as ordered by the physician and acknowledged the lack of a policy for the use of TED hoses.
Failure to Ensure Safe Transfers and Medication Administration
Penalty
Summary
The facility failed to provide an environment free from accidents and hazards by not ensuring that a Certified Nursing Assistant (CNA) did not transfer a resident from bed to wheelchair using a Hoyer lift without another staff member's assistance. The resident, who had moderately impaired cognition and required substantial assistance with activities of daily living, was transferred by CNA 5 alone, which was against the facility's policy requiring two-person assistance for mechanical lift transfers. This action placed the resident at risk for falls and serious injuries. The CNA admitted to performing the transfer alone because other staff were busy, and the Director of Nursing confirmed that the transfer should have been done with two staff members for safety reasons. Additionally, the facility failed to ensure that residents did not have access to medications at their bedside. A resident with a history of cognitive decline and dependency on staff for daily activities was found with a bottle of lidocaine 4% roll-on at their bedside. The medication was not supposed to be left unattended with the resident, as per the facility's policy. The Licensed Vocational Nurse responsible for the resident's medication administration did not know how long the lidocaine bottle had been in the room or when it was last administered. The Director of Nursing confirmed that the medication should not have been left at the bedside due to safety concerns. These deficiencies highlight lapses in adherence to the facility's policies on safe transfers and medication administration, which are critical for preventing accidents and ensuring resident safety. The failure to follow these protocols placed residents at risk for falls, injuries, and potential medication misuse.
Failure to Label Medication with Expiration Date
Penalty
Summary
The facility failed to label a bottle of valproic acid solution with an expiration date, which was observed in one of the medication carts. This deficiency was identified during an observation and interview with a Licensed Vocational Nurse (LVN), who acknowledged the importance of labeling medications with expiration dates to ensure proper usage and disposal. The Director of Nursing (DON) also confirmed that the medication should have been labeled with an expiration date according to the facility's policy and procedure. The affected resident, identified as Resident 70, had a history of dementia, Alzheimer's disease, and major depressive disorder. The resident's physician had prescribed valproic acid to manage dementia-related behaviors, including physical aggression. The failure to label the medication with an expiration date increased the risk of administering ineffective or potentially harmful medication to the resident. The facility's policy indicated that all drugs should be labeled in accordance with state and federal requirements, and containers with missing labels should be returned to the pharmacy for proper disposition.
Improper Disposal of Garbage in Kitchen
Penalty
Summary
The facility failed to dispose of garbage and refuse properly by not covering the garbage container next to the hand washing station in the kitchen. During an initial tour of the kitchen, it was observed that the garbage container next to the sink did not have a lid and contained crumpled white paper towels. The Director of Hospitality (DH) confirmed that the sink was used as a hand washing station and that the garbage container did not have a lid. The DH was unsure if the garbage container should be lidded. The Registered Dietitian (RD) later confirmed that the garbage container should have a lid to prevent the possible spread of bacteria after hand washing. The Director of Nursing (DON) also stated that the garbage container should have a lid to prevent cross-contamination and potential illness among residents. A review of the facility's policy and procedure (P&P) titled, Solid Waste Disposal, indicated that garbage containers should be clean, lined, and covered at all times. The P&P further stated that during periods of constant use in food production, food services, and dish room areas, garbage cans may remain uncovered if local jurisdiction allows this practice. However, the garbage container next to the hand washing station was not in constant use and should have been covered according to the facility's policy.
Failure to Maintain Timely Medical Records
Penalty
Summary
The facility failed to maintain timely resident medical records for one resident when the Physical Therapy (PT) Initial Evaluation dated 11/8/2023 was not documented until 4/4/2024. This delay in documentation was confirmed by the Physical Therapist (PT 1) during a phone interview, where PT 1 admitted that the documentation was completed late and should have been done on the same day the service was provided. The Director of Nursing (DON) also confirmed that all documentation should be completed within the day or as soon as it happens to ensure accuracy and completeness. Resident 38, who was admitted to the facility with diagnoses including polyosteoarthritis, morbid obesity, and abnormalities of gait and mobility, had a Minimum Data Set (MDS) indicating various levels of assistance required for daily activities. The delay in documenting the PT Initial Evaluation had the potential for inaccurate medical documentation and could cause a delay in the provision of appropriate interventions for the resident. The facility's policy stated that documentation must be completed within 24 hours of service, which was not adhered to in this case.
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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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