Ridgecrest Regional Transitional Care And Rehabili
Inspection history, citations, penalties and survey trends for this long-term care facility in Ridgecrest, California.
- Location
- 1081 North China Lake Boulevard, Ridgecrest, California 93555
- CMS Provider Number
- 555877
- Inspections on file
- 24
- Latest survey
- March 18, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ridgecrest Regional Transitional Care And Rehabili during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in foodservice sanitation and food handling, including a resident found with unrefrigerated milk at unsafe temperatures, improper storage of raw eggs below raw beef, unsanitary kitchen conditions such as dirty drains and vents, a cracked light fixture cover, and failure to properly sanitize three ice machines according to manufacturer guidelines.
Essential equipment, including a food preparation sink and two ice machines, were not maintained in safe operating condition due to improper plumbing without required air gaps and floor sink drains, as well as environmental issues such as peeling paint, cracks, and dirty floors near one ice machine. These deficiencies were confirmed through observation, interviews, and review of regulatory requirements and facility policy.
Surveyors found that call lights were not within reach for four residents, including one with limited mobility, one whose call light was out of reach over the headboard, one who could not locate her call light while in a wheelchair, and one whose call light was on the floor. Staff confirmed in each case that the call lights should have been accessible, in accordance with facility policy.
Three residents were not informed about the process to file a grievance, as required by facility policy. Interviews revealed that two cognitively intact residents and one with moderate cognitive impairment did not know how to file a grievance or could not recall being informed, despite policies mandating staff to provide this information.
The facility did not maintain the required minimum CNA direct care hours per patient day on multiple occasions, as confirmed by staff interviews and record reviews. Staff reported frequent short staffing, and the facility was unable to provide complete staffing documentation for the requested period. The deficiency was related to the facility's failure to follow its own policy on sufficient and competent nursing staffing.
The QAPI committee did not identify or address multiple infection prevention and control deficiencies, including improper cleaning of glucometers, lack of staff education, failure to implement enhanced barrier precautions, and insufficient surveillance by the Infection Preventionist. These issues were not discussed or documented in the most recent QAPI meeting.
Multiple infection control deficiencies were observed, including improper storage of distilled water for a CPAP machine on a commode, a nurse returning a dropped medical device kit to the treatment cart, lack of comprehensive infection surveillance and documentation by the IP, failure to implement Enhanced Barrier Precautions for residents with wounds or indwelling devices, and repeated use of glucometers on different residents without cleaning or disinfection between uses.
The facility did not ensure that mandatory infection control training was provided and documented for several LVNs and RNs, as required by its own policy. Interviews and record reviews revealed that staff could not recall receiving recent infection control training, and the Infection Preventionist was unable to provide documentation or details of the training content.
A resident's bathroom had a persistent strong urine odor, as reported by the resident, a family member, a CNA, a housekeeping aide, and the environmental services supervisor. Despite daily cleaning, the odor remained, affecting the comfort and home-like environment for the resident and visitors.
The facility did not develop or implement care plans for two residents with active infections—one receiving IV antibiotics for a UTI and another with chronic wound cellulitis—despite changes in their conditions and facility policy requiring ongoing assessment and care plan updates.
A resident's preference for a lacto-vegetarian diet, which includes dairy but excludes eggs, was not clearly specified or communicated in the diet order. The term 'vegetarian' was used broadly in the care plan and medical record, and the order was not clarified with the physician as required by facility policy and professional standards, resulting in a deficiency in meeting professional standards of quality.
Two residents were placed at risk due to inadequate safety measures and supervision. One resident's bathroom grab bar was slippery and lacked secure grip tape, leading to a fall and ongoing safety concerns. Another resident was left unsupervised on the patio with a non-functioning phone, preventing her from calling for assistance. Staff interviews revealed inconsistent supervision practices, and the resident's care plan indicated a need for staff support due to moderate cognitive impairment.
Two residents with orders for opioid pain medications reported uncontrolled pain, and review of their MARs showed that while pain medications were administered for high pain scores, staff did not document follow-up assessments of medication effectiveness as required by facility policy. The DON confirmed that such monitoring and documentation should have occurred.
A resident's insulin vial was not labeled with their name, as only the outer box contained identifying information. During medication administration, an LVN confirmed that this was standard practice, and the DON stated that vials were not labeled to avoid covering medication details. The consultant pharmacist and facility policy both indicated that insulin vials should be labeled with the resident's name to prevent medication errors.
The facility did not follow planned menus or honor dietary needs and preferences for several residents, including serving incorrect portions on a renal diet, failing to provide a registered dietitian-developed lacto-vegetarian menu for a resident requiring a mechanical soft diet, and serving a disliked food item despite clear documentation. These actions resulted in residents not receiving meals consistent with their individualized nutritional requirements and preferences.
The Infection Preventionist did not follow facility policy for infection control surveillance, failing to collect, analyze, and report data or implement Enhanced Barrier Precautions (EBP) for residents with wounds, indwelling devices, or infections. Multiple residents with ulcers, cellulitis, and Foley catheters did not have EBP signage or PPE available, and staff were unfamiliar with EBP procedures, resulting in a lack of infection control measures.
A resident in an LTC facility missed doses of Insulin Glargine and Potassium due to the facility running out of these medications. The resident, diagnosed with diabetes mellitus, was not given her morning dose of Insulin Glargine and missed several doses of Potassium. The responsibility for medication availability was on the floor nurses, who failed to reorder the medications in time, contrary to the facility's policy on timely administration.
A resident with Type 2 diabetes filed grievances about not receiving a dinner tray and a loud kitchen door, but the facility failed to investigate or resolve these issues within the required timeframe. The resident was not informed of any findings or corrective actions, and staff interviews revealed disorganization in handling grievances.
A resident with Type 2 diabetes did not receive her insulin medications on time, as per the facility's policy. The resident experienced anxiety and physical symptoms due to the late administration of both short-acting and long-acting insulin. The DON and LVNs confirmed the delays and the lack of timely documentation on the MAR.
The facility failed to accommodate the needs of two residents, leading to delays in care. One resident reported call lights taking 20 minutes to be answered, while another waited two hours in a wet brief due to staff shortages. CNAs were often assigned 11 to 17 residents, making it difficult to provide timely care. Facility policies required calls to be answered within five minutes, but this standard was not met.
A resident did not receive medications as ordered, including missed doses of insulin and delayed administration of Ozempic. The facility's medication records confirmed these discrepancies, and the Quality Assurance Nurse acknowledged a data entry error and lack of proper documentation.
A resident's mail was opened without permission by an Administrative Service Manager in Training (ASM), violating the facility's policy on mail privacy. The ASM assumed the letter was related to a medication issue the resident mentioned and opened it without consent. The facility's policy requires mail to be delivered unopened unless the resident requests assistance, which must be documented.
A resident's grievances were not resolved by the facility, as evidenced by incomplete grievance reports and lack of communication. The facility's policy requires prompt resolution and communication of findings, which was not adhered to in this case.
The facility failed to maintain adequate supplies, causing discomfort for two residents due to shortages of chux, wipes, and briefs. Staff interviews revealed issues in the supply ordering process, with the Unit Secretary lacking training to prevent shortages and new admissions not being considered. The facility's policy indicated that incontinence care supplies should be provided to meet residents' needs.
The facility failed to implement a care plan for a resident who made a threat to kill an LVN. The care plan required hourly monitoring, but documentation was missing for multiple hours on two consecutive days. The DON acknowledged the missing documentation, which was against the facility's policy on comprehensive, person-centered care plans.
A resident with severe cognitive impairment and high fall risk fell and sustained a major injury because the bed alarm was not activated. Multiple staff members confirmed the alarm was not turned on, despite the care plan requiring it. The facility's policy on fall risk management was not followed, leading to the incident.
A resident with a history of inappropriate behavior was not adequately supervised, leading to an incident where he engaged in sexual misconduct with another resident who had severe cognitive impairment. Despite previous warnings and documented behaviors, the facility failed to implement effective monitoring and interventions, resulting in the abuse of a vulnerable resident.
Multiple Foodservice Sanitation and Food Handling Deficiencies Identified
Penalty
Summary
The facility failed to maintain sanitary conditions and safe food handling practices in several areas of its foodservice operation. One resident, who was cognitively intact, was found with three unopened cartons of milk left unrefrigerated in her room, with two cartons present since the morning and one from the previous night. The milk was measured at temperatures above 72°F, well above the safe holding temperature, and the facility's policy identified milk as a potentially hazardous food that should not be kept in the danger zone for more than four hours. In the kitchen, raw pasteurized shell eggs were stored below a pan of covered raw beef in the walk-in refrigerator, contrary to the facility's posted policy and standard food safety practices. The Dietary Manager was unaware of the correct storage order, and both the Dietary Manager and Registered Dietitian acknowledged that the facility's policy was not followed. Additionally, multiple unsanitary conditions were observed in the kitchen, including extensive buildup of debris and discoloration in floor drains, accumulation of dust on ceiling vents above exposed food, cracked and chipped flooring around drains, and areas of pooled water. Cleaning schedules did not include floor sink drains, and these areas were not being cleaned or reported for maintenance as required by facility policy. Further deficiencies included a cracked cover on a light fixture in the dish machine room, which had not been identified or reported for repair, posing a risk of foreign object contamination. Three ice machines were not sanitized according to the manufacturer's guidelines; the Maintenance Supervisor used a cleaner that was not an approved sanitizer and missed the required sanitizing step. The facility's policies required ice machines to be cleaned and sanitized per manufacturer instructions, but this was not being followed.
Deficient Plumbing and Environmental Conditions for Food Prep Sink and Ice Machines
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically regarding the plumbing and installation of a food preparation sink and two ice machines. In the kitchen, the food preparation sink was observed to have a pipe directly plumbed into the wall, lacking the required air gap and floor sink drain as specified by the Food and Drug Administration Food Code (FDAFC) and California Health and Safety Code. The Maintenance Supervisor confirmed that the sink's plumbing did not include an air gap and was unaware of this requirement. An external compliance officer also confirmed that the sink's discharge setup was not compliant and would require a project record for correction. Additionally, two ice machines located near separate nursing stations were found to be non-compliant with both manufacturer guidelines and FDAFC requirements. One ice machine lacked a visible air gap or drain, while the other had a pipe inserted into a plastic pipe, preventing the necessary one-inch air gap. The compliance officer noted that the air gap installation was incorrect and that the drain piping should be copper with proper fittings. These deficiencies were confirmed through direct observation and interviews with the Maintenance Supervisor. Further observations revealed that the area surrounding one of the ice machines had environmental deficiencies, including cracks and crevices in the wall, peeling paint, and a dirty floor with cracked tiles. These conditions were contrary to FDAFC requirements for smooth, cleanable surfaces and the facility's own policy, which mandates that walls and ceilings be free of chipped or peeling paint and that such areas be repaired promptly. The presence of these conditions could provide harborage for pests and hinder effective cleaning.
Failure to Ensure Call Lights Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents, as observed during multiple room visits. In one instance, a resident with limited mobility was found lying on her side and appeared restless, with her sensitive call light tied to the right upper side rail, which she could activate. A licensed vocational nurse confirmed that the call light should be within the resident's reach. Another resident's call light was observed hanging over the headboard, out of reach, and a certified nursing assistant acknowledged that the resident should be able to access it. Additionally, a resident sitting in a wheelchair next to her bed did not have a call light within reach and was unaware of its location, stating it was likely mixed up in the bed linens. The certified nursing assistant present confirmed that the call light should have been accessible. In a separate observation, another resident's call light was found on the floor, and the attending certified nursing assistant stated it should be in the resident's hand or within reach. The facility's policy requires that residents be provided with a means to call staff for assistance and that calls for help are answered promptly.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to ensure that three of seven sampled residents were informed of the process to file a grievance. During interviews, one resident stated he did not know how to file a grievance, and another resident reported not remembering if the facility had informed her about the grievance process, instead choosing to address issues directly with staff. A third resident also stated she did not know how to file a grievance and had not been informed by the facility about the process or whom to contact. Record reviews showed that two of these residents were cognitively intact, while one had moderate cognitive impairment, as indicated by their BIMS scores. A review of the facility's policies and procedures confirmed that staff are required to inform residents or their representatives about where to obtain grievance forms and how to file a grievance or complaint. Despite these policies, the sampled residents interviewed were either unaware of the process or could not recall being informed, indicating a failure by the facility to communicate this information as required.
Failure to Maintain Minimum CNA Staffing Levels and Documentation
Penalty
Summary
The facility failed to follow its policy and procedure regarding sufficient and competent nursing staffing for all 73 residents when Certified Nursing Assistant (CNA) direct care service hours per patient day (DHPPD) fell below the minimum standard of 2.4 on multiple occasions. On 3/1/25, the actual CNA DHPPD was 2.31, and on 3/2/25, it was 2.24, as confirmed by the Director of Nursing (DON) during a record review. Staff interviews revealed that when staff called off work, the remaining staff had to divide up the tasks, resulting in frequent short staffing. Both a Licensed Vocational Nurse (LVN) and a CNA confirmed that working short staffed was a common occurrence. The facility was unable to provide complete DHPPD documentation for the requested six-month period, only supplying records for select dates. The facility's policy, dated August 2022, states that minimum staffing requirements imposed by the state are adhered to but are not necessarily considered sufficient for competent staffing. The lack of adequate CNA staffing and incomplete documentation had the potential for residents' care needs not to be met by staff.
QAPI Committee Failed to Address Infection Control Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify, develop, and implement action plans to address infection prevention and control deficiencies. During a review of the most recent QAPI meeting minutes, it was found that the committee only documented infection rates for urinary tract infections, respiratory infections, and skin infections, without addressing other infection control concerns. The QAPI meeting did not include discussion or documentation of infection prevention and control issues identified by the survey team. Surveyors identified several infection control deficiencies that were not recognized or addressed by the facility, including failure to clean and disinfect glucometers between resident use, lack of infection prevention and control education for staff, failure to implement enhanced barrier precautions, and inadequate surveillance activities by the Infection Preventionist. The Administrator confirmed that these issues were not identified or discussed in the QAPI meeting, despite being present in the facility.
Infection Control Failures in Multiple Practices
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several instances. In one case, a resident with obstructive sleep apnea who used a CPAP machine stored three opened gallons of distilled water on top of a commode, which the resident occasionally used. The Infection Preventionist (IP) confirmed that this storage method was unsanitary. Additionally, a Treatment Nurse (TN) was observed dropping a packaged medical device kit from the treatment cart onto the floor, then placing it back into the cart next to an opened package of gauze, acknowledging that this was improper practice. The IP did not follow the facility's policy and procedure for monitoring compliance with infection control. The IP only monitored hand hygiene and PPE use, excluding other critical areas such as glucometer use and cleaning. Documentation of staff noncompliance and corrective actions was lacking, and infection surveillance data was not reported to the QAPI committee as required by policy. Furthermore, Enhanced Barrier Precautions (EBP) were not implemented for residents with wounds or indwelling medical devices, and staff, including the IP, LVN, CNA, ADON, DSD, and DON, demonstrated a lack of knowledge regarding EBP requirements, signage, and PPE use. The facility also failed to clean and disinfect glucometers between resident use according to manufacturer instructions. Two LVNs were observed using the same glucometer on multiple residents without cleaning or disinfecting the device between uses. The IP confirmed that glucometers should be disinfected after each use with appropriate wipes and contact time, and the facility's policy and the device manual both required cleaning and disinfection between uses. These failures were observed during direct care activities and interviews with staff.
Failure to Provide and Document Mandatory Infection Control Training
Penalty
Summary
The facility failed to follow its own policy and procedure regarding employee training on infection control for a significant number of its licensed nursing staff, including 11 Licensed Vocational Nurses and 4 Registered Nurses. During interviews and record reviews, it was found that the Infection Preventionist could not recall the content of the training provided and was unable to produce documentation of the training. Additionally, at least one nurse could not remember the last infection control training attended. The facility's policy required all staff to complete orientation and training on preventing the transmission of healthcare-associated infections, but records and staff interviews indicated this was not consistently done. As a result, licensed nursing staff were unaware of standard infection prevention precautions.
Persistent Urine Odor in Resident Bathroom
Penalty
Summary
A deficiency was identified when a resident's bathroom had a persistent and strong odor of urine, which was noted by the resident, a family member, a CNA, a housekeeping aide, and the environmental services supervisor. The family member reported that the odor was present whenever the bathroom door was left open and had been noticeable during daily visits over a three-week period. The resident, who was assessed as cognitively intact, also confirmed the unpleasant smell. The CNA and housekeeping aide both acknowledged the ongoing urine odor, particularly in the mornings, despite daily cleaning efforts. The environmental services supervisor confirmed that the odor persisted during their assessment. Review of the facility's infection prevention and control policy indicated that the facility is required to maintain a safe, sanitary, and comfortable environment. However, the continued presence of the urine odor in the resident's bathroom demonstrated a failure to provide a home-like and comfortable environment as required by policy. This deficiency was based on direct observations, interviews with staff and family, and review of facility records.
Failure to Develop and Implement Care Plans for Residents with Infections
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with active infections, as required by its own policy and procedure. One resident was observed with an intravenous (IV) catheter and receiving IV antibiotics for a urinary tract infection (UTI) after oral antibiotics were found to be ineffective. Despite the presence of an active infection and a change in treatment, there was no care plan addressing the UTI documented in the resident's electronic medical record. The Minimum Data Set Coordinator confirmed that a care plan should have been in place for this condition but was not found. Another resident had a diagnosis of cellulitis of the left lower limb, as indicated in the Client Diagnosis Report. Upon review of the medical record, the Minimum Data Set Coordinator was unable to provide a care plan for the resident's chronic wound cellulitis. The facility's policy states that assessments and care plans should be ongoing and revised as residents' conditions change, but this was not followed for these two residents with infections.
Failure to Clarify and Communicate Resident's Lacto-Vegetarian Diet Order
Penalty
Summary
The facility failed to ensure that a resident's diet order was clarified to reflect the individual's specific preference for a lacto-vegetarian diet, which includes dairy products but excludes eggs. The Nutrition Risk Assessment documented the resident's preference for a vegetarian diet with dairy but no eggs, and the Plan of Care noted that vegetarian alternatives would be offered. However, there was no documentation specifying the exact nature of the vegetarian preference, nor was the diet order updated to include the lacto-vegetarian specification. The registered dietitians acknowledged that the term 'vegetarian' is broad and should be resident-specific, and that it is standard practice to clarify such preferences with the physician responsible for the resident's care. Record review and interviews revealed that the diet order in the medical record only indicated a mechanical soft ground diet without specifying the lacto-vegetarian requirement. The facility's policy and procedures, as well as the Academy of Nutrition and Dietetics guidelines, require that diet names and orders be consistent and clearly defined across all documentation and communication tools. The facility's own diet manual also specifies the need to clarify the correct category of vegetarian diet. The lack of clarification and communication regarding the resident's specific dietary needs resulted in a deficiency related to ensuring services meet professional standards of quality.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for two residents, resulting in accident hazards and lack of appropriate assistance. For one resident, the grab bar in the bathroom was slippery due to the use of silicone cream, and the grip tape intended to provide a non-slip surface was not properly secured. The resident demonstrated that his hands slipped on the grab bar and reported a previous fall when attempting to use the bar. Despite staff being aware of the fall and the resident's concerns about safety, the grab bar remained inadequately adapted, with blue tape that did not provide a secure grip. Another resident was left unsupervised on the patio without a reliable means to call for assistance. The resident was given a phone to use, but it did not function properly, leaving her unable to request help when needed. Staff interviews revealed inconsistent practices regarding supervision and checking on residents outside, with some staff stating checks should occur every 20 to 30 minutes, while others indicated more frequent checks for residents with cognitive impairment. The resident's care plan indicated dependence on staff for activities and social interaction, and her cognitive assessment showed moderate impairment, yet she was left without adequate supervision or a functioning call device.
Failure to Monitor and Document Pain Medication Effectiveness
Penalty
Summary
The facility failed to monitor and document the effectiveness of pain medications for two residents who reported experiencing uncontrolled pain. Resident 35 had an order for Dilaudid 2 mg every 6 hours as needed for pain, and Resident 55 had an order for Norco 5/325 mg every 6 hours for pain. Both residents reported ongoing, uncontrolled pain during interviews. Review of their Medication Administration Records (MARs) showed that pain medications were administered in response to high pain scores, but there was no documentation of follow-up to assess or record the effectiveness of the medications after administration. The Director of Nursing (DON) confirmed during interviews and record reviews that nurses are expected to check and document the effectiveness of pain medications after each administration, as outlined in the facility's policy and procedure for pain assessment and management. Despite this policy, there was no evidence in the MARs that the effectiveness of the administered opioids was monitored or documented for either resident during the reviewed period.
Insulin Vials Not Labeled with Resident Name
Penalty
Summary
Insulin vials used for a resident were not labeled with the resident's name or other identifying information. During a medication pass, an LVN prepared to administer insulin by removing a box from the medication cart that was labeled with the resident's name, but the insulin vial inside the box was only labeled with the medication name and not the resident's name. The LVN confirmed that each resident had a dedicated insulin vial, but the labeling was only on the outside box, not on the vial itself. The Director of Nursing stated that insulin vials were not labeled with resident names and that the label was only placed on the box to avoid covering the medication name on the vial. The facility's consultant pharmacist indicated that best practice is to label both the insulin vial and the box with the resident's name to prevent mix-ups. A review of a National Library of Medicine document and the facility's own policy confirmed that insulin vials should be labeled with the patient's name, consistent with professional standards and facility policy.
Failure to Follow Menus and Honor Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that menus were followed and met the individualized nutritional needs of residents, as evidenced by three separate incidents involving different residents. In one case, a resident on a therapeutic renal diet was served 2 oz. of gravy instead of the 1 oz. specified in the planned menu. The food service assistant used a 2 oz. ladle, and neither the staff member plating the tray nor the staff member checking trays for accuracy identified the error. The resident's meal tray card and the planned therapeutic menu both indicated the correct portion, but the menu was not followed. Another incident involved a resident with a lacto-vegetarian preference and a mechanical soft (M/S) ground consistency diet due to being nearly edentulous. The resident was served whole blueberries, which are not allowed on a mechanical soft diet, and there was no pre-planned lacto-vegetarian menu developed by a registered dietitian (RD) to guide staff. The RD confirmed that the facility did not have vegetarian, lacto-vegetarian, or vegan pre-planned menus and that the staff member responsible for plating the meal had not received specific instructions for the resident's dietary needs. The lack of a planned menu resulted in inappropriate food items being served and a lack of variety for the resident. A third deficiency was identified when a resident was served lasagna despite it being listed as a food dislike on the resident's meal tray card. The staff member responsible for checking the tray did not catch the error, and the facility's policies required that food preferences be adhered to and that tray cards accurately reflect resident dislikes and preferences. These failures demonstrate that the facility did not consistently follow its own policies and procedures for ensuring that residents' dietary needs and preferences were met.
Infection Preventionist Failed to Implement Surveillance and Enhanced Barrier Precautions
Penalty
Summary
The Infection Preventionist (IP) failed to demonstrate competency in managing the facility's Infection Prevention and Control Program. The IP did not adhere to the facility's policy and procedure for monitoring compliance with infection control, specifically in surveillance activities, data collection, analysis, tracking, and trending. The IP only monitored hand hygiene and PPE use, excluding other critical areas such as glucometer use and cleaning. Documentation of adherence rates and corrective actions for non-compliance was lacking, and the IP did not provide tracking, trending reports, or analysis of surveillance data to the QAPI committee as required by policy. Enhanced Barrier Precautions (EBP) were not implemented in the facility, despite the presence of residents with wounds, indwelling medical devices, and infections such as ulcers and cellulitis. Observations revealed that residents with these conditions did not have EBP signage or PPE supplies in or outside their rooms. Staff interviews indicated a lack of knowledge and training regarding EBP, with the IP, LVN, CNA, ADON, DSD, and DON all expressing unfamiliarity with EBP criteria, required PPE, and related procedures. The facility's policies required EBP for residents with wounds or indwelling devices, but these were not followed in practice. Multiple residents were identified with conditions that met the criteria for EBP, including open wounds, ulcers, cellulitis, and Foley catheters. Despite this, there was no evidence of EBP implementation, signage, or PPE availability. The facility's policies and job descriptions outlined the IP's responsibility for infection prevention, surveillance, data analysis, and staff education, but these duties were not fulfilled, resulting in the facility's failure to monitor, identify, and control the spread of infections.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident 1, by not administering prescribed doses of Insulin Glargine and Potassium. Resident 1, who was admitted with a diagnosis of diabetes mellitus, missed her morning dose of Insulin Glargine on January 29, 2025, and two doses of Potassium on January 27, 2025, as well as another Potassium dose earlier in the month. The missed doses were due to the facility running out of these medications, as confirmed by the Medication Administration Record and interviews with the resident and staff. Interviews with the Licensed Nurse (LN) and the Director of Nursing (DON) revealed that the responsibility for ensuring medication availability lies with the floor nurses, who are expected to reorder medications before they run out. The facility's policy on administering medication, revised in April 2019, states that medications should be administered safely, timely, and as prescribed. However, the failure to reorder medications in a timely manner led to the resident missing critical doses, as documented in the Medication Administration Record and Order History.
Failure to Resolve and Communicate Grievances
Penalty
Summary
The facility failed to adhere to its policy and procedure for recording and investigating grievances for a resident who had filed multiple grievances. The resident, who has Type 2 diabetes mellitus, reported not receiving a dinner tray on one occasion, which led her to purchase food out of concern for her blood sugar levels. Despite filing a grievance about this incident, the resident was not informed of the findings or any corrective actions taken by the facility. Additionally, another grievance regarding a loud kitchen door was also not resolved or communicated to the resident. Interviews with facility staff, including the Social Services Designee and the Administrator, revealed that the grievances were not investigated or resolved within the required timeframe. The Social Services Designee admitted to being disorganized with handling grievances, and the Dietary Supervisor was unaware of any grievances related to the kitchen. The facility's policy requires that grievances be investigated and resolved within 14 working days, with findings communicated to the resident, but this process was not followed in these instances.
Failure to Administer Insulin Timely
Penalty
Summary
The facility failed to adhere to its policy and procedure on administering medications, specifically insulin, for a resident diagnosed with Type 2 diabetes mellitus. The resident reported receiving her insulin more than an hour too late or too early, which caused her to feel anxious, nervous, experience shortness of breath, and shakiness. A review of the Medication Administration Record (MAR) revealed multiple instances where the resident's insulin was not administered at the scheduled times. For example, Insulin Human Regular, a short-acting insulin, was administered hours after the scheduled time on several occasions, and Insulin Glargine, a long-acting insulin, was also given late on different dates. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) confirmed the late administration of insulin and the lack of timely documentation on the MAR. The facility's policy, dated April 2019, mandates that medications be administered safely, timely, and as prescribed, with documentation on the MAR immediately after administration. The DON acknowledged the expectation for timely administration and documentation, while the LVNs confirmed that more than an hour's delay from the scheduled time is considered late.
Failure to Provide Timely Resident Care
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents, leading to potential delays in care. Resident 2 reported that call lights sometimes took 20 minutes to be answered, which was not acceptable and raised concerns about emergency situations. Resident 2's Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 15, showing cognitive intactness. Resident 1 experienced a significant delay in care, having to wait two hours in a wet brief due to staff shortages, which made her feel dehumanized. Her MDS showed a BIMS score of 14, indicating cognitive intactness. Interviews with Certified Nursing Assistants (CNAs) revealed that they were often assigned 11 to 17 residents per shift, making it difficult to provide timely care. CNA 1 reported having 17 residents on a recent shift, which made it challenging to answer call lights and provide showers, resulting in longer wait times for residents. CNA 2 also reported feeling rushed and unable to take breaks due to being assigned 14 residents frequently. The facility's policies on staffing and call systems were reviewed, indicating that calls for assistance should be answered within five minutes, but this standard was not met, contributing to the deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for a resident, which had the potential to lead to adverse outcomes. During an interview, the resident reported being sent to an out-of-town appointment with an insulin pen but no needle, resulting in missed insulin administration before lunch. Additionally, the resident stated that their Ozempic medication, which should be administered weekly on Fridays, was delayed until Saturday. The medication records for September and October 2024 confirmed these discrepancies, showing missed doses and lack of documentation by licensed staff. The Quality Assurance Nurse (QAN) confirmed the findings, noting that the Ozempic was held due to a data entry error and was not administered as ordered. The facility's policy and procedure for administering medications, revised in April 2019, stipulates that medications should be administered safely, timely, and as prescribed, within one hour of the scheduled time unless specified otherwise. However, the records showed instances where medications were either missed or held without proper documentation or explanation, indicating a failure to adhere to these guidelines.
Violation of Resident's Mail Privacy
Penalty
Summary
The facility failed to ensure the privacy of a resident's mail, resulting in a violation of the resident's rights. During an interview, the resident reported that an Administrative Service Manager in Training (ASM) handed her a letter from her insurance company that was already opened. The letter was addressed to the resident, and she did not give permission for it to be opened. The resident questioned the ASM about who opened her mail, but did not receive a response. A review of the resident's Interdisciplinary Progress Note (IDTPN) indicated that the ASM had the letter in the office and opened it, assuming it was related to a medication issue the resident had mentioned. The ASM confirmed in an interview that he opened the letter without the resident's permission, as he assumed it was the document the resident was referring to. The facility's policy and procedure on mail and electronic communication, revised in May 2017, clearly states that mail should be delivered unopened unless the resident requests assistance, which should be documented in the resident's plan of care.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to resolve grievances filed by one of the three sampled residents, identified as Resident 1. During an interview, Resident 1 stated that she had filed grievances, but the facility did not resolve them. A review of the Resident/Family Concern/Grievance Report (RFCGR) for Resident 1, dated 4/22/24, 5/1/24, and 5/4/24, revealed that the grievances were not completed. There was no follow-up, no resolution, and the forms were not signed off by the administration. Additionally, Resident 1 did not sign the forms to indicate that the grievances had been resolved. The facility's policy and procedure on grievances, revised in April 2017, requires that the administrator and staff make prompt efforts to resolve grievances to the satisfaction of the resident. The policy states that upon receipt of a grievance, the grievance officer should review and investigate the allegations and submit a written report to the administrator within five working days. The resident should be informed verbally and in writing of the findings and actions to be taken. However, the facility did not adhere to these procedures, as evidenced by the incomplete grievance reports and lack of communication with Resident 1 regarding the resolution of her grievances.
Supply Shortages Lead to Resident Discomfort
Penalty
Summary
The facility failed to ensure adequate supplies were available for two residents, leading to unmet care needs and discomfort. Resident 1 reported that the facility frequently runs out of chux (underpads) and wipes, particularly at night. Resident 2 also experienced shortages of large briefs and chux, occurring about twice a month. When supplies ran out, staff resorted to using briefs that were either too large or too small, causing leaks or discomfort for Resident 2. Interviews with facility staff revealed issues in the supply ordering process. The Unit Secretary, responsible for placing supply orders, indicated she was trained on how to place orders but not on preventing shortages. A Certified Nursing Assistant noted that the facility's new admissions were not considered when ordering supplies, contributing to the shortages. The facility's policy and procedure document, revised in April 2021, stated that routine personal hygiene items, including incontinence care supplies, should be provided to meet residents' needs during covered Medicare/Medicaid stays.
Failure to Implement Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to ensure that a care plan was implemented for one of the sampled residents when the behaviors were not monitored hourly. Specifically, Resident 1 had made a threat to kill an LVN, and the care plan required hourly rounding to monitor the resident's location, behavior, and activity. However, the documentation of this monitoring was missing for multiple hours on two consecutive days, as evidenced by the absence of entries in the Administration Order Text for those dates and times. During an interview, the Director of Nursing acknowledged the missing documentation. The facility's policy and procedure on comprehensive, person-centered care plans, which includes measurable objectives and timetables to meet the resident's needs, was not followed. This lapse in monitoring and documentation had the potential to result in unmonitored behaviors and delayed psychosocial interventions for Resident 1.
Failure to Monitor Bed Alarm Leads to Resident's Fall and Injury
Penalty
Summary
The facility failed to monitor the efficacy of a bed alarm for a resident, resulting in an unwitnessed fall and a major injury. The resident, who had severe cognitive impairment and was at high risk for falls, was found on the floor with a transverse fracture of the right patella. The bed alarm, which was supposed to be activated as per the resident's care plan, was not turned on at the time of the fall. Multiple staff members, including LVNs and CNAs, confirmed that the bed alarm was not activated. The resident's care plan indicated the need for a bed alarm due to the high risk of falls, but staff failed to ensure it was functioning. The Director of Nursing and other staff members acknowledged that the bed alarm was not turned on and that it should have been. The facility's policy on fall risk management stated that position-change alarms should not be the sole intervention but should assist staff in identifying patterns and routines. However, the staff did not verify the bed alarm's functionality, leading to the resident's fall and subsequent injury. The facility's investigation confirmed that the bed alarm was not activated by the staff, and there was no system in place to ensure its proper functioning.
Inadequate Supervision Leads to Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when another resident, who had a history of inappropriate behavior, was not adequately supervised. Resident 2, who was cognitively intact and independent with mobility, engaged in inappropriate sexual behavior with Resident 1, who had severe cognitive impairment and was not ambulatory. On the day of the incident, Resident 2 was found in Resident 1's room with the door closed, and Resident 1's brief was down to her ankles. Resident 2 admitted to touching Resident 1's breasts and perineal area. Resident 2 had a documented history of inappropriate behavior, including making sexually explicit comments to staff and crossing boundaries with other residents. Despite these behaviors, the facility's interventions, such as close monitoring and setting healthy boundaries, were not effectively implemented. Staff interviews revealed that Resident 2 had been in Resident 1's room multiple times before the incident, and there was a lack of consistent monitoring to prevent such occurrences. The facility's policy on abuse prevention emphasized protecting residents from abuse by anyone, including other residents. However, the facility did not adequately identify and investigate the potential for abuse, nor did it protect Resident 1 from further harm. The failure to supervise Resident 2 appropriately and the lack of effective interventions contributed to the incident of abuse against Resident 1.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
