Santa Rosa Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Rosa, California.
- Location
- 4650 Hoen Avenue, Santa Rosa, California 95405
- CMS Provider Number
- 055854
- Inspections on file
- 71
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Santa Rosa Post Acute during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain a safe smoking environment, provide adequate supervision, and properly care plan for residents who smoke. The outdoor smoking area and adjacent maintenance/housekeeping space were cluttered with cardboard, wood pallets, debris, overfilled trash bins, and accessible maintenance and housekeeping chemicals and aerosols, with a shed door left open and numerous cigarette butts scattered on the ground. Several residents with varying cognitive and physical impairments, including those with hemiplegia, schizophrenia, COPD, fractures, and histories of falls, were allowed to smoke unsupervised despite facility policies and contracts specifying designated smoking times and supervision requirements. One resident struck another in the face during an unsupervised altercation in the smoking area, another resident’s coat had burn holes from a cigarette while he was alone, a resident requiring supervised smoking and unable to self‑propel was left outside unattended and extinguished cigarettes with his fingers and stored butts in his pocket, and another resident used a plastic wheelchair cup holder as an ashtray. Smoking care plans were missing or not initiated timely for some smokers, and the DON and other staff acknowledged that smoking rules were not enforced, residents went out to smoke at any time, and staff were not adequately prepared to manage safety in the smoking area.
Two residents with cognitive and psychiatric impairments were involved in a physical altercation in the smoking area when one resident refused to share a cigarette and lighter and the other struck him in the face, as confirmed by witness statements and the facility’s own investigation. Required 72‑hour COC monitoring was not fully documented for either resident, with multiple shifts lacking nursing notes despite staff and the DON stating that every shift should monitor and document changes after such incidents. Additionally, one resident who had hit another was assessed as able to smoke independently and was observed smoking outside without staff supervision, even though his care plan called for monitoring of the smoking area and staff reported they had been instructed to supervise the residents while smoking.
A resident with intact cognition and multiple medical conditions, including diabetes and difficulty walking, was in bed when another cognitively impaired resident with vascular dementia entered the room, verbally threatened to kill and expressed hatred toward him, then punched and bit him on the hand. An LN had previously observed the aggressive resident in the hallway in disarray and called for a CNA to assist, but the CNA was occupied with another resident when the incident occurred. The LN responded after hearing the victim call out, removed the aggressive resident from the room, and later noted obvious bite marks with droplets of blood on the victim’s hand. Documentation reflected that the victim sustained a human bite to the right hand, and the facility’s abuse policy states that residents have the right to be free from abuse.
A resident with diabetes and end-stage renal disease experienced a significant medication error when staff failed to follow person-centered care planning for hypoglycemia, administered insulin doses incorrectly and without proper documentation, and did not use a Spanish interpreter to communicate with the resident. The resident became unresponsive due to hypoglycemia, and staff did not administer glucagon per protocol, resulting in the need for emergency hospital treatment.
Three residents did not receive multiple prescribed medications, including heart failure, antidepressant, anti-fungal, pain, psoriasis, and thyroid treatments. The MARs showed missed doses, and interviews confirmed that available emergency stock was not used and that staff did not document contacting the pharmacy or physician as required. The DON and Administrator confirmed these were medication errors and that facility policy was not followed.
A resident with dementia and cardiomegaly reported sexual abuse by a CNA, but the CNA was allowed to work a shift after the allegation was known, before a full investigation was completed. The DON identified the alleged perpetrator but did not immediately remove him from the facility, contrary to policy, allowing continued access to residents.
A resident with moderate cognitive impairment alleged that a male CNA exposed himself and forced her to touch him, but the facility failed to conduct a thorough investigation as required by policy. Documentation was inconsistent due to improper record-keeping, and key staff and resident interviews were omitted. Another resident also reported inappropriate touching by the same CNA, but this was not properly addressed or reported.
Two residents were involved in an incident of resident-to-resident abuse, but staff did not notify family representatives or physicians, failed to complete required incident reports, and did not document interdisciplinary team notes or initiate care plans as required by facility policy.
An allegation of abuse involving two residents with dementia was not reported to the appropriate authorities within the required timeframe. The facility delayed notification by five days due to a misunderstanding of reporting requirements, despite policy mandating immediate reporting of suspected abuse.
A resident made an abuse allegation that was not reported to the State, Ombudsman, and law enforcement within the required two-hour timeframe, as the facility delayed reporting until the following day. Interviews with staff, including LNs, the Social Services Assistant, DSD, administrator, and DON, revealed a lack of knowledge about the correct reporting timeframe, with most believing that only abuse with injury required reporting within two hours. The facility's policy required immediate reporting, defined as within two hours, for all abuse allegations.
A resident with dementia and a history of wandering repeatedly entered other residents' rooms, causing distress by taking personal items. Despite complaints and awareness of the issue, the facility failed to implement effective measures to manage the behavior, leading to emotional distress among affected residents.
A facility failed to provide timely access to medical records for several residents, including one with Central Cord Syndrome, due to delays caused by the legal department's review process. Despite the facility's policy allowing verbal requests, residents faced repeated delays and were informed that formal legal requests were necessary. The facility's policy required access within 24 hours and copies within two business days, but these standards were not met, affecting six out of 15 sampled residents.
A resident with a DNR order was resuscitated by nurses at an LTC facility, despite her documented wishes. The resident, who had intact cognition and was her own responsible party, was found unresponsive and CPR was initiated before her DNR status was realized. This resulted in physical, psychosocial, and financial harm to the resident, who now faces a financial burden due to the need for assisted living care.
The facility failed to respond appropriately to a scabies outbreak, affecting 41 residents. The infection preventionist did not implement surveillance or report the outbreak to the local health department, delaying additional resources and assistance. Despite one resident testing positive for scabies, the Director of Nursing took a conservative approach, treating residents prophylactically without confirming the diagnosis. The facility's policy required reporting outbreaks according to CDC guidelines, which was not followed.
A resident's family experienced frustration due to the facility's failure to provide a reliable communication channel. Phone calls to the facility were often unanswered, particularly in the evenings, leading to difficulties in contacting the resident. The facility's phone system was unreliable, and staff were not always available to answer calls. The DON acknowledged the issue but stated there was no policy on handling calls.
A resident did not receive prescribed doses of Lyrica, leading to unrelieved pain and an emergency room transfer. The facility failed to ensure medication availability, contrary to physician orders and facility policy. The DON confirmed the oversight, noting the nurse should have notified the physician about the depleted supply.
The facility failed to provide consistent access to communication for residents with their families after 5 p.m. and on weekends. Two residents and their families reported frustration due to unanswered calls, which was corroborated by staff interviews and observations. The issue was attributed to insufficient staffing during these times, impacting residents' ability to communicate with loved ones.
A resident with multiple health issues, including Dysphagia and cognitive deficits, lost 7.8 pounds in one week due to inadequate nutrition and weight monitoring. Despite needing 1:1 feeding assistance, the resident was often left to eat independently, resulting in less than 50% meal intake. The facility failed to follow weight monitoring protocols, leading to the resident's discharge and subsequent emergency treatment for dehydration.
The facility failed to complete Baseline Care Plans (BCPs) within the required 48-hour timeframe for several residents, including those with significant medical conditions. Staff interviews revealed a lack of awareness regarding the BCP process and its importance, leading to potential risks in resident safety and care quality.
The facility failed to maintain adequate staffing levels, resulting in delayed responses to call lights and unmet resident needs. Several residents reported long wait times for assistance, with some waiting over two hours. Staff interviews confirmed frequent short-staffing, impacting their ability to provide timely care and posing safety risks.
The facility failed to serve food at an appetizing temperature, affecting several residents. Observations showed food items were below acceptable temperature ranges, and staff admitted to not checking temperatures before serving. Residents reported receiving cold, bland, and sometimes undercooked meals, leading to dissatisfaction and reliance on outside food. Staff acknowledged the importance of proper food temperature to prevent safety risks like weight loss and inadequate nutrition.
A resident with specific dietary needs was not provided with a vegan menu, despite his preference and his wife's communication to the facility. The facility lacked a plant-based menu, and staff were unaware of the need to provide vegan meals, resulting in the resident receiving vegetarian meals instead. This oversight potentially compromised the resident's nutritional intake, as the facility did not ensure the meals met his dietary requirements.
The facility failed to employ a certified Dietary Manager (DM) to oversee food and nutrition services in the absence of a full-time Registered Dietician (RD). The DM, who was not certified, was responsible for managing the dietary department despite lacking the necessary qualifications. The Director of Nursing (DON) and the Administrator were aware of the DM's uncertified status, and the facility lacked a policy for hiring a certified DM.
Unsafe Smoking Environment, Inadequate Supervision, and Poor Smoking Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, hazard‑free smoking environment and to provide adequate supervision and care planning for residents who smoke. Surveyors observed the designated outdoor smoking area at the back of the facility to be a 10 ft by 10 ft covered space open to the parking lot, with a table, a wooden chair, a standing cigarette butt receptacle, and a carpet mat. Numerous cigarette butts were scattered on the ground under the shade structure, and residents and staff confirmed that not everyone used the ashtray and that the area was often dirty and only occasionally swept. Approximately 10–12 ft beyond the smoking area, the maintenance/housekeeping shed and surrounding grounds contained multiple empty to full cardboard boxes, tarped boxes and furniture, wood pallets and slabs, a plastic crate with spray bottles and a plastic bottle of cleaning solution, random debris, and two overfilled garbage bins. One shed door adjacent to the smoking area was left open and unattended, allowing access to maintenance supplies, tools, chemical solutions, aerosols, documentation, broken equipment, and boxes of glass fluorescent tube lights stored in a cluttered, disorganized space. The Life Safety/Housekeeping Director acknowledged that the shed and the overflowing garbage bins were hazardous and that flammable aerosol items and boxes of ethyl alcohol‑based hand sanitizer were stored there. The facility also failed to provide adequate supervision in the smoking area, which contributed to resident‑to‑resident abuse and unsafe smoking practices. Resident 1, with hemiplegia/hemiparesis and moderately impaired cognition (BIMS 12), was assessed as able to smoke without supervision and had signed the smoking policy and contract. Resident 2, with paranoid schizophrenia and severely impaired cognition (BIMS 5), was also assessed as independent and allowed to smoke without supervision, with his conservator signing the smoking policy and contract. Resident 3, cognitively intact (BIMS 15) with COPD, was likewise allowed to smoke unsupervised. Resident 4, with COPD, adult failure to thrive, and moderately impaired cognition (BIMS 11), was assessed as requiring supervision to smoke, and Resident 5, with a right femur fracture and history of falls and moderately impaired cognition (BIMS 11), was also assessed as requiring supervision. Resident 6, cognitively intact (BIMS 15) with a Colles fracture and repeated falls, was assessed as independent to smoke without supervision. Despite facility smoking policies and resident contracts specifying set smoking times and supervision requirements, surveyors observed residents smoking unsupervised outside of scheduled times. Resident 2 and Resident 3 were seen smoking alone, with Resident 3 positioned in the parking lot past the first row of cars. Resident 2 was observed with two small burn holes in the front of his coat, which he attributed to a burning cigarette that went out on its own while he was alone. An incident of resident‑to‑resident abuse occurred in the smoking area when Resident 2 hit Resident 1 on the right side of the face during an altercation while both were outside smoking unsupervised. Progress notes and care plans for both residents documented the incident and indicated that staff were to continue to monitor the smoking area, but staff interviews revealed that increased supervision after the altercation lasted only briefly and that there were not enough staff to consistently supervise smoking times or prevent residents from going out to smoke independently. Resident 4, who required supervision and was non‑ambulatory, was observed smoking outside unsupervised in his wheelchair, with both legs wrapped in kerlix gauze from ankles to knees. He reported that a CNA had brought him outside and left him in the sun, and he stated he could not help himself since his legs were wrapped. He was seen extinguishing his lit cigarette with his fingers and placing the butt in his coat pocket, and he needed assistance to turn his wheelchair and open the door to re‑enter the building. Resident 1 was observed flicking his cigarette into a plastic cup holder attached to his wheelchair, which contained ash and later two cigarette butts; the Activities Director and DON acknowledged that using a plastic cup holder as an ashtray was not allowed and posed a fire hazard. The facility also failed to adequately incorporate residents’ smoking status and supervision needs into their care plans. Resident 4’s care plan report contained no evidence of a smoking care plan, despite his documented need for supervised smoking. Resident 6’s smoking care plan was not initiated until the time of the survey, even though she had been admitted months earlier and had signed the smoking policy and contract. Facility policies required that any smoking‑related privileges, restrictions, and concerns, including the need for close monitoring, be noted on the care plan, and the DON stated that smoking status should be care planned within seven days of admission so staff would know a resident is a smoker and whether supervision is required. Staff interviews confirmed that care plans are used to guide monitoring and actions, including assessing whether residents are safe to use and keep lighters, and that without appropriate care planning, staff may not be aware of residents’ smoking needs. The DON acknowledged that residents who required supervision should not be outside unsupervised, that residents sometimes went out to smoke at any hour despite rules, that the smoking rules were not enforced, and that staff were not prepared for the interaction that occurred between Resident 1 and Resident 2 in the smoking area. Facility policies and job descriptions emphasized maintaining a safe environment, identifying safety risks and environmental hazards, and ensuring safe smoking practices. The Safety and Supervision of Residents policy stated that the facility strives to make the environment as free from accident hazards as possible and that resident supervision is a core component of safety. The Maintenance Service policy and the Maintenance Director and Housekeeper job descriptions required maintaining buildings and grounds in good repair and free from hazards, inspecting storage and work areas, and maintaining a safe, orderly, and clean environment free of obstacles. The Smoking Policy‑Residents documents, including the version signed by residents and responsible parties, specified designated smoking times, required that smoking‑related privileges and monitoring needs be noted on care plans, and stated that residents with smoking privileges may not keep smoking articles outside of designated times and that violations could result in loss of smoking privileges or discharge. Despite these written expectations, observations, interviews, and record reviews showed that the smoking area and adjacent maintenance/housekeeping area were cluttered and hazardous, that residents smoked unsupervised and outside of designated times, that unsafe methods of extinguishing cigarettes were used, and that smoking care plans were missing or delayed for some residents, resulting in unmet care needs and inadequate care planning.
Failure to Protect Residents From Abuse and Incomplete Post‑Incident Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse during and after a resident-to-resident altercation. One resident with hemiplegia, hemiparesis following cerebrovascular disease, and anxiety disorder, and with moderately impaired cognition (BIMS score 12), was involved in a physical altercation with another resident diagnosed with paranoid schizophrenia and systemic lupus erythematosus, whose cognition was severely impaired (BIMS score 5). According to the SBAR and interviews, the incident occurred in the smoking area when the cognitively impaired resident asked the other resident for a cigarette and lighter, was refused, and then struck the resident on the right side of the face. Witness accounts varied slightly regarding whether the first resident swung his arm or elbowed the second resident, but all accounts and the facility’s own investigation confirmed that physical contact and a resident-to-resident altercation occurred. The facility did not complete required 72-hour monitoring following this change of condition for either resident. Documentation showed that for the first resident, monitoring was recorded on the day of the incident during evening and night shifts, and on the next two days for all shifts, but there was no evidence of any 72-hour monitoring on the third day for any shift. For the second resident, monitoring was documented on the day of the incident during evening and night shifts, and on the following day for morning and evening shifts, but not for the night shift. On the third day, monitoring was documented only for the morning shift, with no evidence of monitoring for the evening and night shifts, and no monitoring at all on the fourth day. Nursing staff and the DON stated that any change in condition required 72-hour monitoring every shift, documented in progress notes, and emphasized that this was especially important for residents involved in an abuse allegation. The facility also failed to implement and maintain protective supervision measures in the smoking area after the altercation. The second resident’s care plan noted involvement in the incident and that he had hit the other resident on the right side of the face, with staff expected to continue to monitor the smoking area. However, a smoking observation/assessment completed later that same day indicated that this resident could smoke independently without supervision and that the IDT had decided he may smoke without supervision. Observations on subsequent days showed this resident smoking outside without staff present and sitting unattended in the smoking area. Staff interviews indicated that, although there was a brief period when more staff were outside to supervise, this increased supervision only lasted about a day, and the Activities Director reported that staff were told to supervise the two residents when smoking but stated they did not have the manpower to always be outside and could not prevent residents from going out to smoke outside of scheduled smoking times. The DON acknowledged that the smoking assessment allowing unsupervised smoking conflicted with the recent abuse allegation and the facility’s stated expectation of supervised smoking times.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Human Bite
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident entered his room and bit him on the hand. Resident 1 had been admitted in November 2025 with diagnoses including diabetes mellitus, difficulty walking, and morbid obesity, and had a BIMS score of 15, indicating no memory impairment. Resident 2 was admitted in December 2025 with vascular dementia and anxiety disorder and had a BIMS score of 1, indicating severe memory impairment. On 1/13/26, Resident 1’s SBAR form documented that Resident 2 wandered into Resident 1’s room, was confused and angry, and bit Resident 1 on the right hand, resulting in impaired skin integrity and risk for pain, discomfort, and infection. On the day of the incident, a licensed nurse observed Resident 2 in the hallway in disarray and called for a CNA to assist Resident 2 back to his room. The CNA was occupied assisting another resident when the nurse heard Resident 1 call out, “He bit me.” The nurse then went to Resident 1’s room, removed Resident 2 from the room, and later assessed Resident 1, observing obvious bite marks with droplets of blood on his hand. In a subsequent interview, Resident 1 reported that he had been in bed when Resident 2 charged toward him, stated “I’m going to kill you and I hate you,” then punched and bit him. The facility’s abuse prevention policy states that residents have the right to be free from abuse, but this incident occurred despite that policy.
Failure to Ensure Safe Insulin Administration and Hypoglycemia Management
Penalty
Summary
A resident with end-stage renal disease and insulin-dependent type 2 diabetes mellitus experienced a significant medication error due to multiple failures in care planning, medication administration, and communication. The resident's care plan did not include specific interventions for the administration of glucagon during hypoglycemic episodes, nor did it address the resident's risk for refractory hypoglycemia, despite a prior hypoglycemic event. The facility also failed to ensure that the glucometer used for blood glucose monitoring was accurately tracking dates and times, and it did not associate blood sugar values with specific residents, leading to confusion in documentation and care. On the day of the incident, a nurse administered insulin at a time that did not correspond with the scheduled order, and subsequently gave two doses of insulin within a short period (1 hour and 18 minutes). The nurse did not document a critically high blood glucose value of 434 mg/dL, nor was the physician notified of this abnormal result. Additionally, the nurse did not use a Spanish language interpreter to communicate with the resident, who primarily spoke Spanish, when administering insulin. The resident reported that he attempted to refuse the insulin due to feeling unwell and having vomited, but the nurse proceeded with the administration regardless. Later, when the resident became unresponsive with a blood glucose level of 50 mg/dL, another nurse failed to administer glucagon as per facility protocol, citing inability to locate the medication and not considering the emergency kit as a resource. Instead, oral interventions were attempted, but the resident was unable to swallow. Emergency services were called, and the resident required life-saving treatment at a hospital. The sequence of events was compounded by incomplete and inaccurate documentation, lack of timely physician notification, and inadequate communication among staff.
Failure to Administer Medications as Ordered and Lack of Required Documentation
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for three residents. One resident, admitted with congestive heart failure and adjustment disorder with depressed mood, did not receive multiple doses of her heart failure medication, antidepressant, and topical ointment for skin redness as documented in the Medication Administration Record (MAR). Another resident with Alzheimer's disease missed a scheduled dose of anti-fungal powder for moisture-associated skin damage. A third resident, diagnosed with recurring shoulder dislocation and psoriasis, did not receive her prescribed pain-relieving patch, topical cream for psoriasis, or her thyroid medication as ordered. Interviews and record reviews confirmed that the missed doses were not due to medication unavailability alone. The Infection Preventionist (IP) verified that the facility's emergency medication stock contained at least one of the missed medications, but it was not administered. Additionally, there was no documentation that the pharmacy or the physician was contacted regarding the missed doses, nor was there evidence of any instructions or alternative orders being recorded in the residents' charts. The acting Director of Nursing (DON) and the Administrator acknowledged that missing a medication dose constitutes a medication error and could negatively affect residents' health. The facility's policy requires medications to be administered according to prescriber orders and within required time frames, but this was not followed in these cases, as confirmed by the MARs and the lack of appropriate documentation or follow-up.
Failure to Protect Residents from Alleged Perpetrator During Abuse Investigation
Penalty
Summary
The facility failed to protect all residents from sexual abuse by allowing a certified nursing assistant (CNA) who was the subject of an abuse allegation to continue working in the facility before a complete investigation was conducted, as required by facility policy. After a resident with cardiomegaly and dementia reported to a CNA that she experienced sexual abuse by a male staff member, the Director of Nursing (DON) identified the alleged perpetrator based on the resident's description. Despite this, the CNA was permitted to clock in and work a shift on the same day the allegation was reported, providing him access to the resident and others. The DON became aware of the allegation around midday and interviewed the CNA only after he had already started his shift. The CNA admitted to providing showers to the resident and documenting them under another CNA's name. Facility policy requires that residents be protected from abuse and from contact with alleged perpetrators during investigations, but this was not followed. The failure to immediately remove the CNA from the facility during the investigation placed the resident and others at risk.
Failure to Thoroughly Investigate Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse made by a resident with moderate cognitive impairment, who reported that a male CNA exposed himself and forced her to touch his genitals. The resident described the alleged perpetrator in detail, and documentation showed that the CNA had provided her with showers, although records were inconsistent due to the CNA documenting under another staff member's name. The initial investigation by facility staff was limited, with only a single interview of the resident and a review of documentation that did not accurately reflect who had provided care, due to improper documentation practices. The Director of Staff Development (DSD) and Director of Nursing (DON) did not follow the facility's abuse investigation protocol, as required by policy. The DSD did not interview all relevant staff or residents, failed to document staff interviews, and did not include the resident's roommate or other potentially involved individuals in the investigation. The DSD also admitted to not being trained in abuse investigations and concluded the investigation quickly due to perceived inconsistencies in the resident's account. The DON did not assist in the investigation or ensure that it was thorough, and the Administrator did not provide formal training on proper investigative procedures. Additional interviews revealed that another resident reported inappropriate touching by the same CNA, which was disclosed to the Administrator but not acted upon or reported according to policy. The facility's failure to conduct a comprehensive investigation, including interviewing all relevant parties and properly documenting findings, decreased the potential to protect the affected resident and others from harm. The facility's own policy required a thorough investigation, including interviews with all involved staff and residents, but this was not followed.
Failure to Implement Abuse and Change of Condition Policies After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse and change of condition policies for two residents following an allegation of resident-to-resident abuse. Specifically, after one resident reported being physically assaulted by her roommate, staff did not notify the residents' family representatives or physicians, did not complete Special Incident Reports (SIR), and did not document Interdisciplinary Team (IDT) notes in the residents' charts. The investigation summary and interviews confirmed that these required notifications and documentation were not completed, and there was no evidence of care plans being initiated for either resident involved in the incident. Staff interviews revealed that licensed staff were expected to notify family representatives and physicians, complete SIRs, and initiate care plans after abuse allegations, but these actions were not taken. The facility's policies required immediate reporting and documentation of such incidents, as well as interdisciplinary review and care plan updates following significant changes in a resident's condition. Despite these requirements, the records showed no documentation of the necessary notifications, incident reports, or care plan revisions related to the abuse allegation.
Delayed Reporting of Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within the required timeframe for two residents. An incident involving suspected dependent adult or elder abuse occurred between two residents, both of whom had dementia, but the facility did not notify the California Department of Public Health until five days after the event. The Administrator stated that the delay was due to a mistaken belief that reporting was not required when residents had dementia and there was no serious bodily injury. Facility policy required immediate reporting of suspected abuse, defined as within two hours, but this was not followed in this case.
Failure to Timely Report Abuse Allegation and Staff Unawareness of Reporting Requirements
Penalty
Summary
The facility failed to implement its abuse policy for one resident when an abuse allegation was made. The incident occurred when a resident reported an allegation of abuse, but the facility did not report the allegation to the State, Ombudsman, and law enforcement within the required two-hour timeframe. Instead, the report was made the following day, exceeding the policy's definition of 'immediately,' which is within two hours for abuse allegations. Interviews with six facility staff members, including licensed nurses, the Social Services Assistant, the Director of Staff Development, the administrator, and the Director of Nursing, revealed a consistent misunderstanding of the required reporting timeframe. Most staff believed that abuse allegations without injury should be reported within 24 hours, and only those with injury within two hours. The Social Services Assistant specifically stated she did not know the required timeframe for reporting abuse allegations. A review of the facility's policy and procedure confirmed that any suspicion of abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source must be reported immediately, defined as within two hours for abuse allegations. The failure to report the abuse allegation within this timeframe, as well as the lack of staff knowledge regarding the correct reporting protocol, led to the deficiency.
Failure to Prevent Wandering Resident from Disturbing Others
Penalty
Summary
The facility failed to provide a homelike environment for three residents when another resident, who had a history of wandering and aggressive behavior, repeatedly entered their rooms, rummaged through their belongings, and took items. This resident, diagnosed with polyneuropathy, vascular dementia, and Alzheimer's Disease, was known to wander and had previously been in a locked-down memory care unit. Despite the known risks, the facility did not take adequate measures to prevent the resident from entering other residents' rooms, leading to emotional distress and anger among the affected residents. Interviews with residents and staff revealed that the wandering resident's behavior was a persistent issue, causing significant distress. Residents expressed frustration and fear over the loss of personal items and the inability to relax in their own rooms. Staff members acknowledged the resident's behavior, noting that she often took items and became aggressive if confronted. The facility's administration was aware of the complaints but failed to implement effective interventions to manage the resident's behavior, instead suggesting that other residents should tolerate the situation. The facility's Director of Nursing admitted to being unaware of the severity of the issue until recently and expressed uncertainty about how to address the residents' concerns. Despite holding meetings with family members and offering reimbursement for missing items, the facility did not provide a concrete plan to prevent further incidents. The lack of action and effective management of the wandering resident's behavior resulted in a failure to uphold the residents' rights to a safe and homelike environment, as outlined in the facility's policy on resident rights.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide residents with copies of their medical records upon request, affecting six out of 15 sampled residents. This deficiency was identified through interviews and record reviews, revealing that the facility's legal department delayed the release of records. Resident 1, who was admitted with Central Cord Syndrome, spinal fusion, and Spinal Stenosis, requested her medical records multiple times, both verbally and in writing, but faced repeated delays and was informed that her records needed legal review before release. Resident 1's Minimum Data Set indicated no cognitive impairment, and she had authorized the release of her records to her attorney. Despite this, the facility's Medical Records Director (MRD) informed her that a formal legal request was necessary, contradicting the facility's policy that allowed for verbal requests. The MRD confirmed that four out of seven residents who requested records between December 2024 and February 2025 had not received them due to pending legal department approval. The facility's policy stated that residents should have access to their records within 24 hours and copies within two business days of a request. However, the MRD and Administrator acknowledged that the facility's legal department's involvement caused delays, and the MRD admitted that the letter sent to Resident 1 contradicted the facility's policy, potentially causing confusion. The Record Release Log showed multiple instances of delayed record releases due to legal review, highlighting a systemic issue in the facility's process for handling medical record requests.
Failure to Honor DNR Order Results in Resident Harm
Penalty
Summary
The facility failed to provide resident-centered care by administering CPR to a resident who had a Do Not Resuscitate (DNR) order in place. The resident, who was her own responsible party and had intact cognition, had a Physician Orders for Life Sustaining Treatment (POLST) form indicating her decision not to be resuscitated. Despite this, Licensed Nurses performed CPR on the resident when she was found unresponsive, which was against her documented wishes. The incident occurred when a CNA found the resident slumped over and unresponsive in her wheelchair. Licensed Nurse A initiated CPR after transferring the resident to a bed, and Licensed Nurse B assisted with the chest compressions. It was only after CPR had been initiated that the nurses became aware of the resident's DNR status, at which point the resuscitation efforts were stopped. The resident was then transferred to the emergency department by paramedics. As a result of the CPR, the resident experienced physical, psychosocial, and financial harm. She survived the medical emergency but now faces a financial burden due to the need for assisted living care, which costs $6,000 per month. The resident expressed feelings of anxiety and depression due to her current situation, which she did not wish to be in. The facility's policies on resident rights and DNR orders were not followed, leading to this deficiency.
Failure to Respond to Scabies Outbreak
Penalty
Summary
The facility failed to appropriately respond to a scabies outbreak, resulting in 41 out of 95 residents developing an itchy rash. The infection preventionist did not implement surveillance for potential cases of scabies when rashes began appearing, did not identify the scabies outbreak, and did not report the outbreak to the local health department (LHD) as per CDC guidance. This failure potentially delayed additional resources and assistance from the LHD to prevent scabies from spreading to all residents and delayed the LHD from investigating potential exposures and further spread in the community. The Director of Nursing (DON) and Infection Preventionist (IP) were aware of the rash outbreak but took a conservative approach, treating residents prophylactically for scabies without confirming the diagnosis. Despite one resident testing positive for scabies in the hospital, the DON did not consider it an outbreak as there was only one confirmed case. The IP did not conduct any tracking of the rashes, did not start a map of the residents with rashes, and did not start a line list to track the rashes until instructed by the LHD. The IP admitted that she should have reported the outbreak to the LHD and should have started tracking when the first resident tested positive. Multiple residents and family members reported rashes and itching, with some residents being diagnosed with scabies by their doctors. The facility's medical director was aware of one confirmed and one suspected case but did not discuss reporting to the LHD. The facility's policy required reporting outbreaks according to CDC guidelines, which define an outbreak as two confirmed cases or one confirmed case and two suspected cases. The IP and DON failed to adhere to these guidelines, resulting in a delayed response to the outbreak.
Failure to Provide Reliable Communication for Resident
Penalty
Summary
The facility failed to provide a reliable communication channel for a resident, leading to difficulties in communication between the resident and her family. The family member reported that phone calls to the facility were often unanswered, particularly in the evenings, which was the only time she could contact her mother. This lack of communication caused frustration and distrust. An internet search confirmed the facility's publicly listed phone number, but calls made to the facility at different times were not picked up. Interviews with staff revealed that the facility's phone system was unreliable due to dependence on internet signal strength, which was inconsistent in the area. The facility had a receptionist to answer calls during business hours, but after hours, the responsibility fell to the staff, who were not always available to answer calls. Observations showed that the phone used for resident calls was not always in its designated place, and there were instances where a resident with dementia answered the phone. The Director of Nursing acknowledged the issue but stated there was no current policy on answering calls or assisting residents with calls.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that met the needs of a resident, resulting in the resident not receiving prescribed doses of Lyrica, a medication used to treat painful nerve diseases. This occurred twice over a seven-day period, contrary to the physician's orders. The resident, who had been on Lyrica for a long time to control pain, experienced unrelieved pain due to the missed doses, which led to a transfer to the emergency room. The family member of the resident reported the missed doses and expressed concern about the risk of withdrawal symptoms. The Medication Administration Records (MARs) indicated that the doses were marked with a code that referred to the nurse's notes, but there was no documentation of any interventions to ensure the medication was available. The Director of Nursing confirmed the missed doses and acknowledged that the morning shift nurse should have realized the medication supply was depleted and notified the physician. The facility's policy on administering medications emphasized that medications should be administered safely, timely, and as prescribed, which was not adhered to in this case.
Communication Access Deficiency in Facility
Penalty
Summary
The facility failed to ensure that residents had consistent access to communication with their responsible parties and loved ones via the facility phone after 5 p.m. and on weekends. This deficiency was observed in two sampled residents, Resident 4 and Anonymous Resident 5, who expressed frustration and concern over the inability to communicate with their families. Interviews with staff and family members corroborated these issues, highlighting that calls to the facility often went unanswered during these times, leading to feelings of frustration and isolation among residents. Resident 4, who has diagnoses including muscle weakness and multiple sclerosis, reported that the facility phone was not answered after 5 p.m. or on weekends, despite the facility's claim of being open 24 hours. This lack of communication access was also experienced by Resident 4's sister, who frequently visited but was unable to reach the facility by phone during these times. Similarly, Anonymous Resident 5 recounted an instance where they attempted to call the nursing station for assistance but received no answer, raising concerns about the potential impact during emergencies. Interviews with licensed nurses and certified nursing assistants revealed that the issue of unanswered phones was well-known within the facility. Staff members acknowledged the difficulty in answering calls due to being occupied with other duties, particularly during nights and weekends when staffing levels were lower. This situation was further confirmed by observations of unanswered calls made to the facility at various times, demonstrating a systemic issue with phone communication access for residents and their families.
Failure to Provide Adequate Nutrition and Monitoring
Penalty
Summary
The facility failed to provide adequate nutrition and weight monitoring for a resident who lost 7.8 pounds, equivalent to 5.3% of their body weight, within the first week of admission. The resident, who has multiple diagnoses including Spastic Quadriplegic Cerebral Palsy, Epilepsy, Dysphagia, and a cognitive communication deficit, was dependent on 1:1 feeding assistance. Despite this requirement, the resident was documented as eating independently 15 times, and their meal intake was less than 50% during their stay. Additionally, the resident's meal trays were left unattended, leading to missed meals without proper staff intervention. The resident's care plan indicated a need for 1:1 feeding assistance and regular weight monitoring, but the facility only recorded two weights within a week, failing to follow the physician's order for weekly weights. The Director of Nursing admitted that only monthly weights were conducted, which did not comply with the prescribed monitoring protocol. The resident's weight loss was not adequately addressed, and there was a lack of documentation for dietary interventions to maintain nutritional and fluid intake. The resident was eventually discharged back to their group home and had to be sent to the emergency department for dehydration. Lab work from the receiving facility indicated elevated Blood Urea Nitrogen levels, confirming dehydration. The facility's policy required evaluation and intervention for significant weight changes, but these were not effectively implemented, leading to the resident's compromised health status.
Failure to Timely Complete Baseline Care Plans
Penalty
Summary
The facility failed to ensure that staff were aware of the Baseline Care Plan (BCP) and its completion timeframe, resulting in untimely completion of BCPs for five sampled residents. This deficiency was identified through interviews and record reviews, revealing that staff members, including Licensed Staff A and B, were not knowledgeable about the BCP completion timeframe. The Social Services Director and the Director of Nursing confirmed that the BCP should be completed within 48 hours of admission, as per regulation and facility policy. However, the Dietary Manager incorrectly stated that the BCP should be completed within 72 hours, indicating a lack of consistent understanding among staff. The untimely completion of BCPs was evident in the cases of five residents, including those with significant medical conditions such as heart failure, Parkinson's disease, atrial fibrillation, and multiple sclerosis. For instance, Resident 1's BCP was completed a day after the required timeframe, and Resident 2's BCP was completed several days late. Additionally, Resident 4 and Resident 7's BCPs were completed long after their admission dates. Anonymous 5, another resident, reported not recalling a baseline care planning meeting, highlighting a gap in involving residents in their care planning. These failures had the potential to compromise resident safety and care quality, as timely BCPs are crucial for identifying and meeting residents' immediate needs upon admission.
Inadequate Staffing Leads to Delayed Care and Resident Concerns
Penalty
Summary
The facility failed to ensure adequate staffing levels, as evidenced by complaints from seven residents who expressed concerns about the lack of staff to meet their needs. Residents reported feeling upset, frustrated, and worried about the potential for emergencies due to the insufficient number of staff. Observations and interviews revealed that call lights were not answered promptly, with wait times ranging from 20 minutes to over two hours, leading to delays in care and unmet needs. Resident 1, with diagnoses including heart failure and Parkinson's disease, had a BIMS score indicating moderately impaired cognition. Resident 2, diagnosed with migraines and atrial fibrillation, reported waiting up to an hour for staff to respond to her call light and receiving meals late. Resident 4, who required assistance with daily activities, stated that staff were often rushed and unable to provide timely care due to being assigned too many residents. Other residents, including Anonymous 3 and 5, shared similar experiences of long wait times and concerns about safety during emergencies. Interviews with staff members, including unlicensed staff and licensed nurses, confirmed that the facility was frequently short-staffed, impacting their ability to respond to call lights promptly. The staffing coordinator acknowledged that the facility required a specific number of CNAs per shift to be considered fully staffed, but this was not consistently achieved. The Director of Nursing and other staff members recognized that delayed responses to call lights posed safety risks, such as falls and inadequate care, yet the issue persisted.
Failure to Serve Palatable and Safe Temperature Food
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and at an appetizing temperature, affecting seven sampled residents. Observations and interviews revealed that food items such as egg omelets, pureed bread, and hot cereal were served at temperatures below the acceptable range, with the hot cereal being particularly cold. Staff members admitted to not taking the temperature of the food before serving, which is against the facility's policy. This oversight was acknowledged by the Dietary Manager, who confirmed that the policy requires food temperatures to be checked to prevent gastrointestinal illnesses. Residents expressed dissatisfaction with the quality and temperature of the food. Several residents reported receiving cold meals regularly, with complaints about the food being bland, lacking flavor, and sometimes not thoroughly cooked. One resident mentioned receiving a raw hotdog and undercooked chicken, which affected their willingness to eat chicken again. The dissatisfaction with the food led some residents to rely on family members to bring food from outside the facility. Interviews with staff, including licensed and unlicensed personnel, highlighted the importance of serving food at the correct temperature to prevent safety risks such as weight loss and inadequate nutrition. The Dietary Manager and Registered Dietician emphasized the necessity of adhering to food safety protocols to ensure the well-being of residents. Despite discussions about implementing a plan to address these issues, the plan had not been put into action at the time of the report.
Failure to Provide Vegan Diet for Resident
Penalty
Summary
The facility failed to ensure that dietary staff were aware of and provided a vegan menu for a resident who required it. Despite the resident's preference for a vegan diet, the facility did not have a plant-based menu or recipes, and the dietary staff were not informed of the need to provide vegan meals. This oversight resulted in the resident receiving meals that did not align with his dietary preferences, potentially compromising his nutritional intake. The resident, who had a history of heart failure, vitamin B12 deficiency anemia, and Parkinson's disease, was dependent on staff for assistance with eating and other daily activities. His wife, acting as his responsible party, had communicated his vegan dietary preference to the facility. However, the facility continued to serve him vegetarian meals due to a lack of updated physician orders and communication between departments. Interviews with staff revealed a lack of awareness and understanding of the resident's dietary needs, with some staff admitting they were unsure if the meals provided met the resident's nutritional requirements. The facility's dietary manager acknowledged the absence of a plant-based menu and the need for one to ensure residents receive adequate nutrition. Despite multiple communications to nursing staff about the resident's vegan preference, the physician's order remained unchanged, and the resident continued to receive inappropriate meals. The facility's policy on menu planning did not specifically address plant-based diets, contributing to the oversight and failure to meet the resident's dietary needs.
Uncertified Dietary Manager Overseeing Services
Penalty
Summary
The facility failed to ensure that there was a qualified staff member with the appropriate competencies and skill sets to carry out food and nutrition services. A Dietary Manager (DM) who was not certified was overseeing dietary services in the absence of a full-time Registered Dietician (RD). The DM confirmed during an interview that she was not a certified Dietary Manager and was still in the process of obtaining her certification. She also stated that she was not a certified food service manager and had no certification at the facility. The DM was responsible for overseeing the kitchen and dietary needs of the residents when the RD was not present, despite lacking the necessary certification. The Director of Nursing (DON) and the Administrator both acknowledged that the current DM was not certified. The RD, who worked part-time and visited the facility two to three times a week, also confirmed that the DM was not certified and was responsible for overseeing the dietary department in her absence. The facility did not have a policy and procedure regarding the hiring of a certified DM, which contributed to the deficiency in ensuring qualified staff for food and nutrition services.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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