The Springs Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwalk, California.
- Location
- 10625 Leffingwell Road, Norwalk, California 90650
- CMS Provider Number
- 055297
- Inspections on file
- 52
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at The Springs Post-acute during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and type 2 DM was started on Lantus insulin at bedtime per a new physician order, and the medication was administered throughout the month without notifying the resident’s responsible party (RP). The RP later learned of the new medication from the resident’s insurance company and reported feeling that her authority and right to participate in the plan of care were undermined. The DON confirmed there was no documentation of notification or discussion with the RP about the initiation of Lantus, despite facility policy requiring prompt notification of the resident’s representative for changes in medical care or treatments.
A resident with severe cognitive impairment and multiple diagnoses developed swelling and discoloration in the hand. Staff attempted to contact the primary physician but did not reach out to the medical director as required by facility policy, resulting in a 13-hour delay before medical orders were received.
A resident with severe cognitive impairment and multiple diagnoses sustained a non-displaced finger fracture of unknown origin. The LVN who received the x-ray results did not report the injury to CDPH, law enforcement, or the Ombudsman within the required two-hour window, and the DON was not informed until several hours later. Facility policy and regulations required immediate reporting of such incidents, but this was not followed.
A resident with multiple medical conditions and moderate cognitive impairment was subjected to a violation of their rights when a CNA, previously restricted from providing care to the resident due to a family complaint, entered the resident's room to care for the roommate. Despite facility policy and known conflicts, the CNA was assigned to the room, resulting in a failure to treat the resident with respect and dignity.
A resident with severe cognitive impairment and a history of falls was not consistently supervised according to their care plan, resulting in multiple falls, including an unwitnessed incident that led to hospitalization for head trauma. Staff were unfamiliar with the resident's routine after a room change, and communication lapses between activity and nursing staff contributed to the deficiency.
A resident with significant mobility impairments and requiring two-person assistance for turning was repositioned by a single CNA, resulting in a fracture of the left forearm. The incident occurred due to understaffing, as other CNAs and nurses were occupied with other duties. The resident, who had conditions such as anoxic brain damage and osteoporosis, was totally dependent on staff for bed mobility. Despite the care plan's requirement for two-person assistance, the CNA proceeded alone, leading to the injury.
The facility failed to provide necessary occupational and physical therapy services to residents with limited range of motion (ROM) and mobility issues. A resident with severe hypoxic ischemic encephalopathy and cerebral infarction did not receive recommended therapy services due to insurance denial, and inaccurate Joint Mobility Screens (JMS) were performed. Other residents did not receive timely evaluations or interventions, such as splints or therapy services, leading to preventable contractures and further decline in their conditions.
The facility failed to respond to call lights in a timely manner for three residents, leading to delays in care. One resident with polyneuropathy and paraplegia reported long wait times, while another with an amputated leg experienced up to 15-minute delays. A third resident with cord compression noted that staff sometimes promised to return but did not. Interviews and records confirmed the issue, despite facility policy requiring immediate response.
The facility failed to accurately code the use of restraints in the MDS for three residents. One resident with severe cognitive impairment had mittens applied, another with Parkinson's disease had mittens to prevent interference with medical devices, and a third with hemiplegia had a mitten to prevent pulling on a gastrostomy tube. These restraints were not documented in the MDS, as confirmed by the MDS Coordinator.
The facility failed to label and date opened food containers, including sandwiches and salads, in the refrigerator, as observed during a kitchen tour. Staff interviews confirmed the responsibility to date prepared foods to prevent serving unsafe food. The facility's policy requires all prepared foods to be labeled and dated, but this was not followed, risking residents' safety.
The facility failed to address unresolved quality deficiencies in restraint monitoring and documentation, as well as accurate resident assessment. A resident with significant medical needs had no documentation for the assessment and monitoring of physical restraints. The LVN admitted the lack of documentation, and the MDSC did not recognize hand mittens as restraints, leading to incorrect coding. The Administrator and DON acknowledged that these issues were identified in previous surveys but not effectively addressed.
The facility did not document COVID-19 vaccination status for all employees, including physicians and consultants, as required by their policy. The IPN was unaware of the need to obtain this information, and the DON confirmed that all staff should be included in the vaccination records. This oversight could potentially place staff and residents at risk for serious COVID-19 outcomes.
A long-term care facility failed to provide a usable call light for a resident with severe cognitive impairment and physical limitations, and another resident had a non-functional call light, leading to delayed care. The facility's policies require functional call systems, but these were not adhered to, impacting resident safety and communication.
A resident with cerebral infarction and legal blindness was not adequately protected from abuse after a verbal altercation with another resident. Despite intervention by an RN, the aggressive resident threw tissue boxes at the vulnerable resident. The facility failed to separate the residents as required, moving the aggressive resident to a room sharing a patio with the victim, contrary to policy.
A facility failed to assess, monitor, and document the use of hand mittens as a restraint for a resident with a G-tube. The resident, with a history of traumatic subarachnoid hemorrhage and hemiplegia, required dependent assistance and had impaired extremities. Despite orders for mitten use with specific release and skin check instructions, staff did not document monitoring in the MAR. Interviews revealed non-compliance with restraint monitoring protocols, contrary to facility policy requiring least restrictive use and documentation.
The facility failed to ensure accurate PASARR screenings for two residents with mental disorders, leading to potential inappropriate placement and unidentified specialized services. One resident with schizophrenia and another with schizoaffective disorder had screenings that did not reflect their mental health diagnoses. The MDS Coordinator and DON acknowledged the inaccuracies, which are against the facility's policy requiring accurate PASARR screenings for all admissions.
A facility failed to implement a comprehensive care plan for a resident with chronic respiratory failure, a tracheostomy, and a gastrostomy, who required bilateral hand mittens to prevent pulling at life-sustaining devices. The care plan did not address the use of hand mittens, despite the resident's dependency on staff for self-care and mobility. The MDS Coordinator and DON acknowledged the importance of care plans in preventing complications, which was not adhered to in this case.
A resident with limited mobility and a history of severe medical conditions was not transferred out of bed daily as required by their care plan. Despite the family's desire for daily transfers, the resident was observed lying in bed over several days. The facility's DON confirmed there was no care plan indicating the family's request for the resident to remain in bed, and the facility's policy required assistance with mobility for residents unable to perform activities of daily living independently.
A facility failed to obtain a podiatry consult for a resident with a thickened toenail on the left big toe. The resident, with conditions such as Down syndrome and chronic kidney disease, required podiatry care every two months, but the last visit was in September 2024. Observations confirmed the need for a podiatry consult, which was not scheduled, delaying necessary foot care.
A facility failed to monitor, assess, document, and discontinue an IV hep lock for a resident after completing IV therapy. The resident, at high risk for infection due to an immunocompromised status, experienced discomfort from the IV hep lock, which remained in place despite the completion of antibiotic therapy. Staff interviews revealed a lack of documentation and adherence to facility policy regarding IV site care and discontinuation.
A facility failed to change the Heat and Moisture Exchanger (HME) for a ventilator-dependent resident as scheduled, risking infection. The HME, part of the ventilator circuit, had not been changed since a specific date, contrary to the facility's policy of daily changes. The resident, with severe cognitive impairment and total dependence on staff, had a care plan indicating a risk of infection at the tracheostomy site.
A facility failed to provide Speech Therapy (SLP) services to a resident with severe brain injuries, as recommended by an SLP Evaluation and ordered by a physician. Despite the resident's need for intensive rehabilitation to assess oral intake safety, the facility did not conduct the necessary therapy or a new evaluation as ordered. The facility's policy required evaluations to be initiated within 72 hours of a physician's order, which was not followed.
A Physical Therapist (PT 2) at the facility provided therapy to a resident with an inactive license. The resident, admitted with multiple diagnoses including a tibia fracture and muscle weakness, required assistance for movement. The Director of Rehabilitation was unaware of the inactive status, and PT 2 mistakenly selected this option, leading to unauthorized practice.
A resident with chronic respiratory failure and other conditions was not offered the pneumococcal vaccine upon admission and readmission, contrary to facility policy. The resident, who lacked decision-making capacity and was dependent on others for care, was at increased risk due to their medical condition. The facility's policy requires vaccine assessment and offering within thirty days of admission, which was not adhered to in this case.
A resident with a history of serious medical conditions experienced a significant change in condition, including a high fever and elevated heart rate, but the facility failed to notify the physician as required. Despite multiple instances of vital signs exceeding the set parameters, the physician was not informed, leading to the resident's transfer to a hospital where they were diagnosed with septic shock and later passed away. Staff interviews revealed a lack of documentation and adherence to notification policies.
A resident with neuromuscular dysfunction of the bladder experienced a change in condition, including a high fever and elevated heart rate, which was not promptly assessed or reported to the physician by the facility staff. The lack of a specific care plan and failure to document vital signs led to a delay in transferring the resident to a hospital, where they were diagnosed with septic shock and later expired.
A facility failed to return a resident's funds to Social Security after discharge, as required by policy. The resident, with severe cognitive impairment, was transferred to a GACH and did not return. Despite this, the facility continued to receive Social Security funds and did not close the Resident Fund Management Service account, which had a balance of $11,649.00. The Business Office Manager did not refund the funds within three business days, as stipulated by the facility's policy.
A resident with severe cognitive impairment and high fall risk experienced multiple falls without revisions to their care plan, resulting in continued falls and injuries. Despite interdisciplinary team discussions to increase monitoring, the care plan was not updated, violating facility policies for comprehensive, person-centered care.
Two residents in an LTC facility experienced delays in receiving incontinence care, resulting in them sitting in soiled diapers for 55 minutes. Despite requests for assistance, CNAs delayed care due to other tasks, leading to discomfort and indignity for the residents. Staff interviews confirmed the importance of timely care to prevent complications, as outlined in the facility's policies.
A resident with severe cognitive impairment and high fall risk experienced multiple falls due to inadequate supervision and lack of care plan revisions. Despite known risks and interdisciplinary team recommendations for increased monitoring, the facility failed to update the care plan, resulting in continued falls and injury.
A resident with hemiplegia and hemiparesis required two-person assistance for bed mobility but was repositioned by a CNA alone, resulting in a scratch on the resident's forearm. The CNA admitted to rushing and not securing the resident's arms properly. The DON noted that the scratch could have been avoided with shorter fingernails and proper arm placement. The facility lacked documentation for regular nail trimming, contributing to the incident.
A resident with respiratory failure and schizoaffective disorder felt sad and depressed after the ADON made an inappropriate comment about finding peace six feet below the ground. The comment was reported by a family member, and interviews confirmed the statement, although it was claimed to be general. The facility's policy on resident rights was not upheld.
A facility failed to report an abuse allegation involving a resident to the CDPH, Ombudsman, and police within the required timeframe. A family member reported that the ADON made an inappropriate comment to the resident, which was documented but not reported. The DON was unaware of the abuse claim due to reliance on verbal reports, and the Administrator did not report the incident, despite policy requirements.
A resident's family member reported an alleged abuse incident involving the ADON, who made an inappropriate comment. The facility failed to assess the resident's safety, notify the physician, or report the incident to authorities. Staff interviews revealed a lack of documentation and follow-up, and the DON and Administrator did not adhere to the facility's abuse reporting policy.
A resident with severe medical conditions was found to have a right femur fracture and knee swelling, but the LTC facility failed to report this injury of unknown origin to the CDPH. Despite the resident's dependency on staff for mobility and no recorded falls, the facility did not comply with reporting requirements, as acknowledged by the DON and other staff.
A resident in an LTC facility was administered Percocet every six hours without proper reassessment of pain levels, despite assessments indicating no pain. The medication was given regularly without parameters for pain levels, and the facility's policies on pain assessment and medication management were not followed. This failure placed the resident at risk for adverse effects.
A facility failed to readmit a resident after hospitalization, citing no available beds despite records showing otherwise. The resident, treated for lethargy and hypotension, was denied return due to a positive test for CRAB, although CMS guidelines allow for such admissions. Interviews confirmed the facility's refusal, contradicting their policy to accommodate returning residents.
Failure to Notify Responsible Party of New Insulin Medication
Penalty
Summary
The facility failed to notify the responsible party (RP) when a resident was started on a new insulin medication, Lantus, resulting in a violation of the RP’s right to be informed and involved in treatment decisions. The resident’s face sheet showed admission with diagnoses including cerebral infarction, metabolic encephalopathy, and type 2 DM. The resident’s H&P dated 8/29/2025 documented that the resident did not have the capacity to understand and make decisions, and the MDS dated 8/14/2025 indicated severe cognitive impairment with the resident rarely or never able to understand and be understood by others. A physician’s order dated 12/8/2025 directed that the resident receive Lantus 16 units subcutaneously at bedtime for type 2 DM, to be held if blood sugar was less than 150. The MAR for 12/2025 showed that Lantus was administered at 9 p.m. from 12/8/2025 through 12/31/2025. During a telephone interview, the RP stated she learned from the resident’s insurance company that Lantus had been started, and she expressed anger that the facility had not informed her of the new medication, stating that the facility undermined her authority and right to contribute to the resident’s plan of care and that she felt distrustful toward the facility. In an interview, the DON stated that review of the medical record revealed no documentation that the RP was notified when Lantus was added and confirmed there was no record of any discussion with the RP regarding Lantus prior to its initiation. The facility’s P&P titled “Change in Resident’s Condition or Status,” dated 5/2022, required prompt notification of the resident, attending physician, and representative of changes in the resident’s medical/mental condition or status and stated that a nurse or healthcare provider would inform the resident of any changes in medical care or nursing treatments, regardless of the resident’s current condition.
Failure to Timely Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to notify a physician in a timely manner regarding a significant change in condition for a resident who developed swelling and discoloration of the left fourth and fifth fingers. The resident, who had diagnoses including Alzheimer's disease, schizophrenia, and Parkinson's disease, was severely cognitively impaired and dependent on staff for daily activities. Documentation showed that staff observed the swelling and discoloration, and initial attempts were made to contact the resident's physician, but there was no immediate response. Follow-up calls and texts were made, but the physician did not respond until approximately 13 hours after the initial observation. Facility policy required staff to contact the medical director if the primary physician could not be reached within 30 minutes, but this protocol was not followed. Interviews with nursing staff and the DON confirmed that the medical director was not contacted as required, resulting in a delay in obtaining medical orders for the resident's condition. The facility's job descriptions and policies emphasized timely physician notification and the use of alternate physicians when the primary was unavailable, but these procedures were not adhered to in this instance.
Failure to Timely Report Fracture of Unknown Origin
Penalty
Summary
The facility failed to report a fracture of unknown origin for a resident to the California Department of Public Health (CDPH), law enforcement, or the Ombudsman as required. The resident, who had diagnoses including Alzheimer's disease, schizophrenia, and Parkinson's disease, was severely cognitively impaired and dependent on staff for daily activities. The resident was found to have swelling and discoloration of the left hand, and subsequent x-ray results confirmed a non-displaced fracture of the fifth finger. Despite the absence of documentation explaining how the injury occurred, the results were not reported to the required authorities within the mandated two-hour timeframe. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) who received the x-ray results did not notify the appropriate agencies immediately, and the Director of Nursing (DON) only became aware of the incident several hours later. Facility policies and job descriptions reviewed during the investigation clearly stated the requirement to report suspected abuse, neglect, or injuries of unknown origin immediately, defined as within two hours. The failure to report the incident in a timely manner delayed the initiation of an investigation and did not comply with both facility policy and regulatory requirements.
Failure to Honor Resident's Right to Dignity and Self-Determination
Penalty
Summary
A deficiency occurred when a Certified Nurse Assistant (CNA) entered the room of a resident who had previously requested not to receive care from that CNA, following a complaint from the resident's family member. Despite an agreement that the CNA would not be assigned to provide care to this resident, the CNA entered the resident's room to provide care to the roommate and closed the curtain for privacy. Staffing records confirmed that the CNA was assigned to the roommate, not the resident in question, but the Director of Nursing (DON) acknowledged that, due to the known conflict and complaints, the CNA should not have been assigned to the room at all. The resident involved had multiple medical conditions, including hemiplegia, hemiparesis, acute respiratory failure, diabetes mellitus, asthma, and post-traumatic stress disorder (PTSD). The resident's cognitive skills were moderately impaired, and they were dependent on staff for all activities of daily living. The facility's policy stated that residents have the right to be treated with respect, kindness, and dignity, and to participate in decision-making regarding their care. The failure to honor the resident's request and the facility's own policy resulted in a violation of the resident's rights.
Plan Of Correction
F550 Resident Rights/Exercise of Rights 1. How corrective actions will be accomplished for those residents found to have been affected by the deficient practice. • Resident 1 remains in the facility and has no complaints/issues about his CNA. • CNA 1 will no longer be assigned to resident '1's roommate and cannot enter room since 08/02/2025. • Resident 1's care plans were reviewed and updated according to his needs. • The DON provided in-service education regarding Resident Rights Policy and Procedures to nursing, rehab, activity, respiratory, and department heads' staff on 08/14/2025, 08/15/2025, 08/18/2025, 08/19/2025, and 08/20/2025. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken. • The Administrator, DON, and Social Services Director (SSD) randomly interviewed alert and oriented residents to address any concerns/issues regarding their CNA, ensuring they are treated with respect, kindness, and dignity, and participate in decision-making regarding their care; no concerns/issues were brought up. • There were no other residents affected by this deficient practice. • The DON provided in-service education regarding Resident Rights Policy and Procedures to nursing, rehab, activity, respiratory, and department heads' staff on 08/14/2025, 08/15/2025, 08/18/2025, 08/19/2025, and 08/20/2025. 3. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not occur. Systemic changes will be achieved through in-service education and corrective action monitoring utilizing the facility quality assurance process. • The DON provided in-service education regarding Resident Rights Policy and Procedures to nursing, rehab, activity, respiratory, and department heads' staff on 08/14/2025, 08/15/2025, 08/18/2025, 08/19/2025, and 08/20/2025. • The RN supervisor and charge nurse will review the assignment sheet every shift to ensure that staff who have issues with the resident will not be assigned to the resident's room and cannot enter the room. Any findings will be corrected immediately and reported to the DSD and DON for follow-up and corrections for future pre-assigned assignment sheets. • The RN supervisor will randomly observe staff daily when providing care to the residents to ensure residents are treated with respect, kindness, and dignity, and that staff comply with resident care plans. Any findings will be corrected immediately and reported to the DON for follow-up and corrective actions. • Department Heads will conduct daily room rounds and interview the residents regarding any concerns/issues regarding their CNA, ensuring they are treated with respect, kindness, and dignity, and participate in decision-making regarding their care. Immediate correction will be carried out upon notice of issues/concerns. Any findings during their room rounds will be discussed in the stand-up meeting for corrective actions and follow-up. • The DSD or designee will continue to provide in-service education regarding Resident Rights. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator and/or DON shall implement, monitor, and evaluate this Plan of Correction. The SSD or designee will recapitulate findings related to Resident Rights issues at the monthly QAA meeting for further evaluation, recommendation, and/or appropriate improvement actions. If it is determined that we have accomplished the objectives in the Plan of Corrections above and the results are successful, then the facility will consider the matter resolved. The QAA Committee will continue to review until the deficiency has been proven resolved for two consecutive months and/or advised by the QAA Committee.
Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure staff familiarity with a resident assessed as high risk for falls. The resident, who had severe cognitive impairment and was dependent on staff for most activities of daily living, experienced multiple falls, including an unwitnessed fall that resulted in hospitalization for head trauma. The facility's care plan and interdisciplinary team (IDT) interventions specified that the resident should not be left unattended in a wheelchair, and that staff should escort or endorse the resident between locations. However, these interventions were not consistently implemented, particularly after the resident was moved to a new room with unfamiliar caregivers. Observations and interviews revealed that staff were not always aware of or adhering to the resident's fall prevention interventions. On one occasion, the resident was found unsupervised in the hallway after wheeling himself from the activity room, contrary to the care plan. Staff interviews indicated that communication between activity and nursing staff was primarily verbal and not documented, leading to lapses in supervision. Additionally, there were no visible indicators in the resident's environment to alert staff to the high fall risk, and staff monitoring intervals may not have been sufficient given the resident's condition. The facility's policies required that interventions be communicated to all relevant staff, implemented consistently, and re-evaluated after each fall. Despite these requirements, the resident continued to experience falls, including in situations where new caregivers were unaware of the resident's routine. The lack of consistent supervision, inadequate communication, and failure to reassess and adjust interventions after each fall directly contributed to the resident's repeated falls and subsequent injury.
Failure to Provide Adequate Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a resident who required two-person assistance for turning and repositioning in bed was not turned and repositioned by one person, resulting in an injury. On February 8, 2025, a certified nursing assistant (CNA 1) turned and repositioned the resident alone, despite the care plan indicating the need for two-person assistance. This action led to the resident sustaining an acute fracture of the distal shaft of the left forearm, necessitating transfer to a general acute care hospital for further evaluation and treatment. The resident, who had been admitted with diagnoses including anoxic brain damage, osteoporosis, and muscle contractures, was totally dependent on staff for bed mobility. The Minimum Data Set (MDS) indicated that the resident had functional limitations and impairments in both upper and lower extremities, placing them at risk for injury. Despite these conditions, CNA 1 proceeded to turn the resident alone due to the unavailability of other staff members, resulting in a loud cracking sound from the resident's left arm during the process. Interviews with staff revealed that the subacute unit was understaffed, leading to situations where CNAs had to perform tasks alone that required assistance. The director of nursing confirmed that the care plan required two-person assistance for the resident's safety, and the director of rehabilitation emphasized the need for careful handling due to the resident's stiffness and contractures. The facility's policy on turning residents also highlighted the importance of reviewing care plans for special needs, which was not adhered to in this case.
Failure to Provide Necessary Therapy Services for Residents with ROM Limitations
Penalty
Summary
The facility failed to provide necessary occupational and physical therapy services to several residents with limited range of motion (ROM) and mobility issues. Resident 76, who had a history of severe hypoxic ischemic encephalopathy and cerebral infarction, was identified as needing occupational therapy for contracture prevention and physical therapy for ankle limitations. Despite these evaluations, the resident did not receive the recommended skilled therapy services due to a denial from the health insurance. The facility also failed to perform accurate quarterly Joint Mobility Screens (JMS) for Resident 76, which inaccurately reported full ROM despite documented limitations. Resident 48 did not receive an occupational therapy evaluation after a decline in elbow ROM was identified, and the facility applied elbow extension splints without professional assessment. Similarly, Resident 61 did not receive an OT evaluation before the application of a right elbow extension splint, and the facility failed to identify ROM decline in the resident's left hand and ankle. Resident 68, who was admitted to hospice care, did not receive passive range of motion (PROM) exercises for the arms and legs as required. The facility's failure to provide restorative nursing aide (RNA) services as ordered for Resident 54 further exemplifies the systemic issue of inadequate care. Interviews with staff and family members revealed that the facility did not provide necessary interventions, such as splints or therapy services, due to insurance denials, and there was a lack of documentation and follow-up on identified ROM limitations. The facility's policies did not require insurance authorization for interventions to prevent ROM loss, yet these services were not provided, leading to preventable contractures and further decline in residents' conditions.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure that call lights for three residents were answered in a timely manner, resulting in a delay of care and services. Resident 34, who was admitted with polyneuropathy, muscle weakness, and paraplegia, required varying levels of assistance with activities of daily living (ADLs) and reported long wait times for call light responses. Resident 45, with a diagnosis of acquired absence of the left leg below the knee and osteomyelitis, also experienced delays in call light responses, with wait times reported up to 15 minutes. Resident 82, suffering from cord compression and reduced mobility, similarly reported that call lights were not answered promptly, and sometimes staff would promise to return but failed to do so. Interviews with the residents and staff, including the Infection Prevention Nurse and the Director of Nursing, confirmed the issue of untimely responses to call lights. The facility's Resident Council Minutes also documented complaints about the delayed response to call lights. The facility's policy and procedure on answering call lights, which was revised in September 2022, stated that call lights should be answered immediately to meet the residents' needs. However, the observations and interviews indicated that this policy was not being followed, leading to the deficiency in care provided to the residents.
Inaccurate MDS Coding for Restraints
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, specifically in the Minimum Data Set (MDS) Section P regarding restraints and alarms. Resident 80, who was admitted with severe cognitive impairment and dependent on all activities of daily living, had mittens applied as a restraint, which was not documented in the MDS. The MDS Coordinator confirmed the oversight during an interview, acknowledging that the MDS was not coded to reflect the use of mittens as restraints. Resident 296, admitted with conditions including Parkinson's disease and chronic respiratory failure, was also found to have hand mittens applied to prevent interference with life-sustaining devices. However, the MDS did not indicate the use of restraints. During an observation, Resident 296 was seen with mittens on both hands, and the MDS Coordinator confirmed that mittens should have been coded as restraints, as they restrict movement and cannot be easily removed by the resident. Similarly, Resident 86, who had a traumatic subarachnoid hemorrhage and hemiplegia, was observed with a mitten on the left hand to prevent pulling on a gastrostomy tube. The MDS did not reflect this restraint use, and the MDS Coordinator admitted to not realizing that mittens are considered restraints. The facility's policy requires comprehensive assessments, and the Resident Assessment Instrument manual specifies that mittens are categorized as limb restraints, which should have been accurately documented in the MDS.
Failure to Label and Date Food Containers
Penalty
Summary
The facility failed to ensure that food containers, once opened, were labeled with an open date and a use-by date, which is a violation of professional standards for food storage and safety. During an initial tour of the kitchen, several items in the refrigerator, including wrapped turkey sandwiches, a large jar of pickle relish, prepared fruit cups, and prepared salads, were found without preparation or use-by dates. This oversight was confirmed during an interview with Dietary Aide 1, who acknowledged that staff are responsible for dating prepared foods to prevent serving potentially unsafe food to residents. Further interviews with staff, including [NAME] 1 and the Dietary Supervisor, reinforced the importance of labeling and dating food items to avoid serving expired or potentially harmful food to residents. The facility's undated policy on labeling and dating of foods requires all prepared foods to be covered, labeled, and dated, either individually or in bulk. The lack of adherence to this policy could lead to residents consuming food that is unsafe, as food should be discarded after three days to prevent bacterial growth.
Failure to Address Quality Deficiencies in Restraint Monitoring and Documentation
Penalty
Summary
The facility failed to identify and address unresolved quality deficiencies, particularly in the areas of assessment, monitoring, and documentation of physical restraints, as well as accurate resident assessment with documentation. These deficiencies were noted during previous surveys but were not corrected through the Quality Assessment and Assurance (QAA) process. The report highlights the lack of effective corrective actions and the absence of documentation in the Quality Assurance Performance Improvement (QAPI) binder regarding these issues. A specific case involved a resident admitted with traumatic subarachnoid hemorrhage, hemiplegia, and generalized muscle weakness, who required dependent assistance for daily activities. The resident's Medication Administration Records (MAR) lacked documentation for the assessment and monitoring of left-hand mitten physical restraints. The Licensed Vocational Nurse (LVN) acknowledged the absence of documentation and stated that the physician's order was not transcribed to the MAR, and no follow-up was conducted. The LVN emphasized the importance of assessing and monitoring restraints every two hours to prevent injury. Further interviews revealed that the Minimum Data Set Coordinator (MDSC) did not recognize hand mittens as physical restraints, leading to incorrect coding in the resident matrix. The Administrator admitted that the issues were identified in previous surveys but were not effectively addressed in QAPI meetings. The Director of Nursing (DON) confirmed that the assessment and monitoring orders for the mitten were not carried out correctly, and these issues were not resolved through the QAA/QAPI committee meetings.
Failure to Document COVID-19 Vaccination Status for All Staff
Penalty
Summary
The facility failed to provide documented evidence of COVID-19 vaccination status for all employees, including physicians and consultants, which was identified during an interview and record review with the Infection Prevention Nurse (IPN). The IPN was unaware of the requirement to obtain COVID-19 immunization status for physicians and consultants. Additionally, during an interview with the Director of Nursing (DON), it was stated that all staff, including board members, licensed practitioners, lab, and hospice personnel, should be included in the vaccination records. The facility's policy and procedure, revised in October 2022, indicated that all staff, regardless of their role or contact with residents, should be vaccinated against COVID-19. This lack of documentation had the potential to place staff and residents at risk for serious outcomes related to COVID-19.
Deficient Call Light System in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident had a call light they could use, and another resident had a working call light, resulting in a delay of care and services. Resident 80, who was admitted with severe cognitive impairment and was dependent on all activities of daily living, had a mitten on their right hand and was unable to move their left hand. Despite having a push button call light placed on their chest, Resident 80 was unable to use it due to their physical limitations. The Infection Prevention Nurse acknowledged that Resident 80 would benefit from an adaptive call light. Resident 30, who had intact cognitive skills but required assistance with various activities, was observed to have a non-functional call light. Despite signaling for help, the call light did not activate, and Resident 30, who had a tracheostomy and was unable to vocalize, mouthed that they had been trying to get assistance for almost an hour. The Registered Nurse Supervisor and Maintenance Supervisor confirmed the importance of a working call light for residents who cannot verbalize their needs, and the Maintenance Supervisor noted that the call light for Resident 30 was not working and needed replacement. The facility's policies and procedures indicated that assistive devices and equipment should be provided to ensure resident safety and independence, and that call lights should be answered immediately. However, the facility failed to adhere to these policies, as evidenced by the non-functional call light for Resident 30 and the inappropriate call light setup for Resident 80. The Director of Nursing emphasized the necessity of a working call light for residents to communicate their needs, especially in emergencies.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect Resident 50 from physical and verbal abuse by not adequately separating them from Resident 197 after a verbal altercation. Resident 50, who has cerebral infarction, muscle weakness, and legal blindness, was involved in a conflict with Resident 197, who has essential hypertension and anxiety disorder. The altercation began when Resident 197 refused to close the patio door despite freezing temperatures, leading to a verbal argument with Resident 50. Despite the intervention of Registered Nurse 2 (RN 2) to calm the situation, Resident 197 later threw two tissue boxes at Resident 50, which was not immediately addressed by relocating Resident 197 to a non-adjacent room. The facility's policy requires staff to separate residents involved in altercations and make necessary changes to care plans. However, after the incident, Resident 197 was moved to a room that shared a common patio with Resident 50, failing to ensure their separation. Interviews with staff, including RN 2, Licensed Vocational Nurse 4 (LVN 4), and the Director of Nursing (DON), revealed that the facility did not follow its policy to prevent further interactions between the two residents, thereby placing Resident 50 at risk for further abuse and feelings of insecurity.
Failure to Monitor and Document Restraint Use
Penalty
Summary
The facility failed to properly assess, monitor, and document the use of hand mittens as a physical restraint for a resident who was at risk of pulling out a gastrostomy tube. The resident, who was admitted with a traumatic subarachnoid hemorrhage, hemiplegia on the right side, and generalized muscle weakness, required dependent assistance for daily activities and had impaired upper and lower extremities on one side. Despite having an order to apply a hand mitten on the left hand with specific instructions for release and skin checks, the facility did not document the necessary monitoring and assessment. During observations, the resident was seen with a hand mitten on the left hand, which was intended to prevent the removal of the G-tube. However, there was no documentation in the Medication Administration Records (MAR) regarding the monitoring and assessment of the mitten use, as the staff failed to transcribe the physician's order to the MAR. Interviews with the Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) revealed that the staff did not follow the protocol for monitoring the restraint every two hours, which is crucial to prevent injury. The facility's policy on the use of restraints emphasizes that restraints should only be used for the safety and well-being of residents after other alternatives have been tried unsuccessfully. The policy also requires that restraints be the least restrictive and used for the shortest time necessary, with ongoing re-evaluation and documentation. However, the facility did not adhere to these guidelines, as evidenced by the lack of documentation and monitoring of the resident's hand mitten, which was considered a restraint due to its restriction of movement.
Inaccurate PASARR Screening for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure accurate Preadmission Screening and Resident Review (PASARR) for two residents, which is a federal requirement to ensure individuals with mental disorders are placed in appropriate facilities. Resident 11 was admitted with diagnoses including schizophrenia, type 2 diabetes mellitus, and essential hypertension. However, the PASARR screening inaccurately indicated that Resident 11 did not have a mental disorder, despite the diagnosis of schizophrenia. The MDS Coordinator confirmed that the PASARR and Minimum Data Set (MDS) were not accurate, which could lead to inappropriate placement and unidentified specialized services for the resident. Similarly, Resident 33 was admitted with a diagnosis of schizoaffective disorder, bipolar type, but the PASARR screening also failed to reflect this mental disorder. The MDS Coordinator acknowledged the inaccuracy in the PASARR and emphasized the importance of correct screening to meet the resident's needs. The Director of Nursing confirmed that the PASARR should be accurate and completed as required by law. The facility's policy and procedure on admission criteria, revised in 2019, mandates Level I PASARR screening for all admissions and readmissions, screening all residents for mental disorders per the PASARR process.
Failure to Implement Comprehensive Care Plan for Resident with Hand Mittens
Penalty
Summary
The facility failed to implement a comprehensive care plan for Resident 296, who was admitted with significant medical conditions including chronic respiratory failure with hypoxia, a tracheostomy, and a gastrostomy. The resident was noted to have bilateral hand mittens applied to prevent pulling at life-sustaining devices, as per an order dated 10/25/2024. However, the comprehensive care plan dated the same day did not address the use of these hand mittens, which was a necessary intervention for the resident's safety and well-being. Observations and interviews revealed that the care plan lacked specific measures to address the resident's use of hand mittens, despite the resident's dependency on staff for all self-care and mobility activities. The MDS Coordinator acknowledged the absence of a care plan for the hand mittens and emphasized the importance of care plans in monitoring and preventing complications. The Director of Nursing also highlighted the role of care plans in addressing residents' needs and diagnoses. The facility's policy on comprehensive, person-centered care plans requires measurable objectives and timeframes, which were not met in this instance.
Failure to Transfer Resident Out of Bed Daily
Penalty
Summary
The facility failed to provide adequate services to a resident with limited range of motion and mobility by not transferring the resident out of bed daily. The resident, who had a history of severe hypoxic ischemic encephalopathy, cerebral infarction, cerebral edema, and required attention to a G-tube, was observed lying in bed on multiple occasions over several days. The care plan for the resident indicated the need for assistance during transfers using a mechanical lift with two to three persons and to apply a helmet when out of bed. However, the resident was not transferred out of bed regularly, as observed during the survey. Family members of the resident expressed their desire for the resident to be transferred out of bed daily, contradicting the facility staff's claim that the family wanted the resident to remain in bed. The family stated that they had only requested the resident to be transferred out of bed on specific occasions, such as when the weather was nice. The facility's Director of Nursing confirmed that there was no care plan indicating the family's request for the resident to remain in bed, and acknowledged that generally, residents are not kept in bed every day. The facility's policy on supporting activities of daily living indicated that care and services should be provided for residents unable to carry out these activities independently, with the consent of the resident and in accordance with the care plan. Despite this policy, the facility did not adhere to the care plan for the resident, resulting in the resident remaining in bed and not being transferred to a Geri chair as needed for comfort and postural support.
Failure to Obtain Podiatry Consult for Resident's Foot Care
Penalty
Summary
The facility failed to obtain a podiatry consult for a resident who was noted to have a thickened toenail on the left big toe. The resident, who was admitted with diagnoses including Down syndrome, chronic kidney disease, and reduced mobility, was dependent on staff for all activities of daily living. The resident's medical records indicated a need for podiatry care every two months for conditions such as mycotic and hypertrophic nails. However, the last podiatry visit was recorded in September 2024, and no subsequent visit was scheduled to address the resident's foot condition. During an observation, the resident's left foot was found to have a thickened and dirty toenail, which was confirmed by the Restorative Nurse Assistant and the Infection Prevention Nurse. The facility's policy on foot care, which emphasizes maintaining mobility and foot health, was not adhered to, as the necessary podiatry consultation was not arranged. This oversight resulted in a delay of needed foot care services for the resident.
Failure to Discontinue IV Hep Lock Post-Therapy
Penalty
Summary
The facility failed to properly monitor, assess, document, and discontinue a peripheral intravenous (IV) hep lock site for a resident after the completion of IV therapy. Resident 42, who was admitted with a right foot open wound, sepsis, and diabetes mellitus, was at high risk for infection due to an immunocompromised medical status. Despite the completion of IV antibiotic therapy on January 15, 2025, the IV hep lock remained in place, wrapped loosely with gauze, causing discomfort to the resident. The resident expressed confusion about the presence of the IV hep lock, as they had not received IV antibiotics since the previous month. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and a Registered Nurse Supervisor (RNS), revealed a lack of documentation regarding IV site care and the discontinuation of the IV hep lock. The Director of Nursing (DON) confirmed that the IV hep lock should have been removed after the completion of therapy to prevent infection. The facility's policy indicated that peripheral catheters should be removed at the completion of therapy, yet this was not adhered to, as evidenced by the absence of documentation and the continued presence of the IV hep lock.
Failure to Change Respiratory Equipment as Scheduled
Penalty
Summary
The facility failed to ensure the timely change of a Heat and Moisture Exchanger (HME) for a ventilator-dependent resident, identified as Resident 40. The HME, which is part of the ventilator circuit and provides humidification to tracheostomy residents, was observed to have not been changed since 1/17/25, despite the facility's policy requiring daily changes. This oversight was confirmed during an observation and interview with a Licensed Vocational Nurse (LVN) and a Respiratory Therapist (RT), who stated that the HME should be changed twice a day to prevent clogging with secretions. Resident 40, who was readmitted to the facility with multiple diagnoses including anoxic brain damage, ventilator dependence, and hemiplegia following a cerebrovascular accident, was noted to have severely impaired cognitive skills and was totally dependent on staff for all activities of daily living. The resident's care plan highlighted a potential for infection related to the tracheostomy site, with a goal to keep the stoma site clear of infection. The failure to change the HME as scheduled had the potential to harbor microorganisms in the respiratory equipment, increasing the risk of infection for Resident 40.
Failure to Provide Speech Therapy Services as Ordered
Penalty
Summary
The facility failed to provide Speech Therapy (SLP) services to a resident, identified as Resident 76, in accordance with the SLP Evaluation recommendations and physician orders. Resident 76, who had a history of severe hypoxic ischemic encephalopathy, cerebral infarction, and cerebral edema, was admitted to the facility with a tracheostomy tube and required gastrostomy tube feeding. The SLP Evaluation, dated August 6, 2024, recommended intensive acute rehabilitation to stimulate pharyngeal abilities and assess the safest level of oral intake, but the facility did not provide these services. The facility also failed to conduct a new SLP Evaluation as ordered by the physician on January 23, 2025. Despite the physician's order for a Speech Therapy evaluation and treatment for possible oral intake, the SLP did not complete the evaluation within the required timeframe. The Director of Rehabilitation acknowledged that the SLP did not complete the documentation in response to the physician's order, and the facility's policy did not require health insurance authorization prior to providing further intervention. During interviews and record reviews, it was revealed that the facility did not have documentation of therapy services being provided to Resident 76 after the initial SLP Evaluation. The Director of Nursing confirmed that the facility's Rehabilitation Policy and Procedures required the evaluation process to be initiated within 72 hours of the physician's order, which was not adhered to in this case.
Inactive License for Physical Therapist
Penalty
Summary
The facility failed to ensure that one of its Physical Therapists (PT 2) had a current and active license to provide physical therapy treatment. This deficiency was identified when PT 2 was observed providing therapy to Resident 90, despite PT 2's license being inactive. Resident 90 had been admitted with several diagnoses, including a displaced fracture of the left tibia, right foot drop, difficulty in walking, and muscle weakness. The resident's Minimum Data Set (MDS) indicated impairments in range of motion in both legs and a dependency on assistance for various movements. PT 2 was scheduled to provide treatment to eight residents, including Resident 90, while holding an inactive license. The Director of Rehabilitation (DOR) was unaware of PT 2's inactive license status until it was reviewed during the survey. The DOR acknowledged that it was both their responsibility and the therapist's responsibility to ensure that the therapist had an active license. PT 2 was also unaware that their license had been placed in an inactive status, which was confirmed by the Physical Therapy Board of California (PTBC). The PTBC stated that PT 2 had mistakenly selected the option to change their license to inactive, which prohibited them from practicing. This oversight resulted in PT 2 providing therapy without a valid license, potentially affecting other residents requiring physical therapy treatment.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to offer the pneumococcal vaccine to Resident 29 upon their admission and readmission, as required by the facility's policy. Resident 29, who was admitted with chronic respiratory failure with hypoxia, traumatic brain injury, and seizures, did not have the capacity to understand and make decisions, as indicated in their history and physical assessment. The Minimum Data Set assessment further noted that Resident 29 was rarely or never understood and was dependent on others for self-care activities. Despite these vulnerabilities, the pneumococcal vaccine was not offered to Resident 29 or their responsible party, as confirmed by the Infection Prevention Nurse during an interview. The Director of Nursing acknowledged that the facility's policy is to offer vaccines, including the pneumococcal vaccine, on the day of admission or the following day. However, this procedure was not followed for Resident 29. The facility's policy, revised in March 2022, states that residents should be assessed for vaccine eligibility prior to or upon admission and offered the vaccine within thirty days unless contraindicated. The failure to offer the vaccine to Resident 29, who had a tracheostomy and was receiving oxygen, increased the risk of the resident acquiring pneumococcal disease.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician when a resident experienced a significant change in condition. The resident, who had a history of acute respiratory failure, bronchopneumonia, seizures, hemiplegia, and neuromuscular dysfunction of the bladder, exhibited vital signs that were outside the parameters set by the physician for sepsis prevention. Despite having a temperature of 103.8°F and a heart rate of 130 bpm, the licensed nurses did not notify the physician as required by the resident's care plan. The report details multiple instances where the resident's vital signs exceeded the thresholds for physician notification, including elevated temperatures and heart rates on several occasions. The failure to notify the physician of these changes in condition resulted in the resident developing an altered level of consciousness and low blood pressure, leading to their transfer to a general acute care hospital. The resident was diagnosed with septic shock and passed away 13 hours after admission to the hospital. Interviews with facility staff revealed that the physician was not informed of the resident's critical condition, and nonpharmacological interventions were attempted without success. The staff acknowledged that the physician should have been notified, and documentation of the resident's condition and interventions was lacking. The facility's policies and procedures for notifying physicians of clinical problems and changes in resident status were not followed, contributing to the deficiency.
Removal Plan
- License Nurse 1 was educated by the DON regarding Change of Condition policy and procedure focusing on immediate notification of the physician as it relates to quality of care.
- In-service education was commenced by the DON and Quality Staff Registered Nurse to all licensed nurses regarding physician notification of the change of condition including but not limited to vital signs that are out of range for the sepsis prevention.
- In-service education was commenced by the DON and/or designee regarding initiation, review, and revision of resident-centered care plan of residents with a diagnosis of neuromuscular dysfunction of the bladder with interventions to prevent the resident from developing urinary tract infection/sepsis and other areas that accurately reflects resident's conditions and care.
- Competency Skills Check for licensed nurses was commenced by DON and Quality Staff Registered Nurse regarding assessing residents' change in conditions, identifying symptoms of infection/sepsis and of change of condition, assess, monitor and implement needed interventions based on residents' change of condition, recognizing symptoms of urinary tract infection and including elevated temperature, hematuria, abdominal pain, and low back pain, and compliance with recognizing, evaluating and monitoring.
- The facility checked Situation, Background, Assessment, Recommendation/Change of Condition. All 161 SBAR/COC showed that medical doctor was notified on a timely manner.
- In-service education was commenced by the DON and/or designee regarding initiation, review, and revision of resident-centered care plan of residents with a diagnosis of neuromuscular dysfunction of the bladder with interventions to prevent the resident from developing UTI/sepsis and other areas that accurately reflects resident's conditions and care.
- In-service education was commenced regarding Physician Notification of the change of condition including but not limited to vital signs that are out of range for the sepsis prevention. 50 out of 50 Registered Nurses/Licensed Vocational Nurses staff received the in-service on Physician Notification of the change of condition including but not limited to vital signs that are out of range for the sepsis prevention.
- Competency Skills Check regarding change of condition was commenced by DON and Quality Staff Registered Nurse. Competency Skills Check regarding change of condition was conducted to 50 out of 50 Registered Nurses/Licensed Vocational Nurses staff.
Failure to Monitor and Notify Physician of Change in Condition
Penalty
Summary
The facility failed to ensure timely assessment and monitoring of a resident who experienced a change in condition, which included a high fever and elevated heart rate. The Licensed Vocational Nurse (LVN) did not assess or document the resident's vital signs after the initial recording of a temperature of 103.8°F and a heart rate of 130 bpm. The resident's physician was not notified of these critical changes, and nonpharmacological interventions were attempted without success. The lack of documentation and failure to notify the physician contributed to a delay in transferring the resident to a general acute care hospital (GACH). The resident, who had a history of neuromuscular dysfunction of the bladder, was not provided with a care plan addressing this condition, which could have included interventions to prevent urinary tract infections and sepsis. Despite the resident's severe cognitive impairment and dependency on staff for mobility, the facility did not have a specific care plan in place to manage the resident's condition effectively. This oversight, combined with the failure to monitor and document the resident's vital signs, resulted in a significant delay in addressing the resident's deteriorating condition. The resident was eventually transferred to the GACH, where they were diagnosed with septic shock and expired shortly after admission. Interviews with facility staff revealed that the primary care physician was not informed of the resident's critical condition, and there was a general lack of adherence to the facility's policy for notifying physicians of significant changes in resident status. The facility's failure to act promptly and follow established protocols contributed to the resident's decline and eventual death.
Removal Plan
- License Nurse 1 was educated by the DON regarding Change of Condition policy and procedure focusing on immediate notification of the physician as it relates to quality of care.
- In-service education was commenced by the DON and Quality Staff Registered Nurse to all licensed nurses regarding physician notification of the change of condition including but not limited to vital signs that are out of range for the sepsis prevention.
- In-service education was commenced by the DON and/or designee regarding initiation, review, and revision of resident-centered care plan of residents with a diagnosis of neuromuscular dysfunction of the bladder with interventions to prevent the resident from developing UTI/sepsis and other areas that accurately reflects resident's conditions and care.
- Competency Skills Check for licensed nurses was commenced by DON and Quality Staff Registered Nurse regarding assessing residents' change in conditions, identifying symptoms of infection/sepsis and of change of condition, assess, monitor and implement needed interventions based on residents' change of condition, recognizing symptoms of urinary tract infection and including elevated temperature, hematuria, abdominal pain, and low back pain, and compliance with recognizing, evaluating and monitoring.
- The facility checked Situation, Background, Assessment, Recommendation/Change of Condition. All 161 SBAR/COC showed that medical doctor was notified on a timely manner.
- In-service education was commenced regarding Physician Notification of the Change of Condition including but not limited to vital signs that are out of range for the sepsis prevention. 50 out of 50 Registered Nurses/Licensed Vocational Nurses staff received the in-service on Physician Notification of the Change of Condition including but not limited to vital signs that are out of range for the sepsis prevention.
- Competency Skills Check regarding Change of Condition was commenced by DON and Quality Staff Registered Nurse. Competency Skills Check regarding Change of Condition was conducted to 50 out of 50 Registered Nurses/Licensed Vocational Nurses staff.
Failure to Return Resident Funds After Discharge
Penalty
Summary
The facility staff failed to return funds to Social Security after a resident was discharged, as required by the facility's policy. The Business Office Manager (BOM) did not refund the resident's funds within three business days, as stipulated in the facility's Policy and Procedure (P&P) titled Links Healthcare Resident Trust Policy. The resident, who had severe cognitive impairment and lacked decision-making capacity, was transferred to a General Acute Care Hospital (GACH) due to oxygen desaturation and did not return to the facility. Despite this, the facility continued to receive Social Security funds for the resident and did not close the Resident Fund Management Service (RFMS) account, which had a balance of $11,649.00 as of January 2025. The deficiency was identified through interviews and record reviews, revealing that the facility did not adhere to its policy of refunding resident trust funds within three business days of discharge. The BOM stated that the account was not closed because the facility anticipated the resident's return, although the Director of Nursing (DON) confirmed that the resident had not returned since the transfer in September 2024. The resident's family member had been requesting the funds since the discharge, but the facility failed to comply with its policy, resulting in the continued holding of the resident's funds.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the care plan for a resident after multiple falls, which resulted in continued falls and injuries. The resident, who was admitted with diagnoses including metabolic encephalopathy, unspecified dementia, and end-stage renal disease, had a care plan indicating a risk for falls due to poor safety awareness, unsteady gait, balance problems, and poor endurance. Despite these risks, the care plan was not updated following falls on specific dates, leading to further incidents. The resident experienced a fall on a specified date, resulting in a questionable fracture of the right scapula, although a subsequent X-ray showed no fracture. The resident was assessed as high risk for falls, but the care plan was not revised to address this increased risk. Another fall occurred on a later date, where the resident was found in a sitting position on the floor with moderate pain, yet again, the care plan was not updated to reflect new interventions or precautions. A third fall resulted in a skin tear and discoloration to the resident's head, and once more, the care plan remained unchanged. The Director of Nursing confirmed that the care plan interventions had not been revised despite discussions in interdisciplinary team meetings to increase monitoring and visual checks. The facility's policies and procedures require that care plans be comprehensive and person-centered, reflecting changes in the resident's condition, but these were not followed, leading to the deficiency.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, resulting in them sitting in wet and soiled diapers for 55 minutes after requesting assistance. Resident 1, who had a history of cerebral infarction and hypertension, required assistance with activities of daily living due to weakness in his lower extremities. On the day of the incident, Resident 1 informed a CNA that he needed to be changed, but it took 55 minutes for the CNA to return with supplies and provide the necessary care. Similarly, Resident 5, who had diagnoses including benign prostatic hyperplasia, generalized weakness, and a below-the-knee amputation, also required assistance with activities of daily living. Resident 5 requested incontinence care from a CNA, but was told to wait due to the impending dinner service. It took 55 minutes for the CNA to return and provide the necessary care, during which time Resident 5 expressed feelings of indignity and discomfort. Interviews with staff, including CNAs, an LVN, and the Director of Nursing, confirmed that the residents' needs were not met in a timely manner, which could lead to complications such as skin breakdown and urinary tract infections. The facility's policies and procedures emphasize the importance of providing timely and appropriate care to maintain residents' dignity and well-being, but these were not adhered to in this instance.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that a resident, who was at high risk for falls, received adequate supervision and care plan revisions following multiple falls. The resident, who had severe cognitive impairment, required assistance with activities of daily living and was at risk for falls due to poor safety awareness and balance issues. Despite these known risks, the facility did not revise the resident's care plan after falls on two separate occasions, leading to a third fall where the resident sustained a skin tear and discoloration to the head. The resident's care plan initially included interventions such as conducting rounds every two hours, reminding the resident to call for assistance, and providing cueing and supervision. However, after the resident experienced falls on two occasions, the care plan was not updated to reflect new interventions or increased supervision. The facility's interdisciplinary team meetings acknowledged the need for increased visual checks and close monitoring, but these changes were not documented in the care plan. The facility's policies and procedures required that interventions be identified and implemented based on the resident's specific risks and causes to prevent falls. Despite this, the facility did not document or revise the care plan to address the resident's ongoing fall risk, resulting in continued falls and injury. The Director of Nursing confirmed that the care plan should have been updated to ensure appropriate care and prevent further harm to the resident.
Inadequate Assistance During Bed Mobility Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) did not turn and reposition a resident who required a two-person physical assist with bed mobility, by himself, without the assistance of another staff member. This resulted in the resident scratching his right forearm with his left hand, causing a scratch measuring 0.2 cm by 2 cm. The resident, who was admitted with diagnoses of hemiplegia and hemiparesis following a cerebral infarction, was totally dependent on staff for bed mobility and required two or more staff for assistance. The resident's care plan indicated a need for a safe environment and assistance with activities of daily living due to a self-care performance deficit related to a cerebrovascular accident. During an interview, the CNA admitted to providing care alone and rushing, which led to not paying close attention to the placement of the resident's arms. The resident was observed with a mitten on the right hand and a closed fist on the left hand, indicating a need for careful handling. The Director of Nursing (DON) concluded that the scratch could have been avoided if the resident's fingernails were shorter and the left arm was secured properly. The facility's policy on activities of daily living indicated that appropriate care and services should be provided for residents unable to carry out ADLs independently, but there was no documentation or schedule for trimming fingernails, which contributed to the incident.
Inappropriate Comment by ADON Affects Resident's Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect when the Assistant Director of Nursing (ADON) made an inappropriate comment. The incident involved a resident with acute and chronic respiratory failure and schizoaffective disorder, whose cognition was moderately impaired. During an interaction, the ADON responded to the resident's request for peace by stating that peace could be found six feet below the ground, which the resident found shocking and verbally abusive. This comment was reported by a family member, leading to the resident feeling sad and depressed. Interviews with the Social Services staff and the Director of Nursing (DON) confirmed the ADON's statement, although it was claimed to be a general comment rather than directed at the resident. The DON acknowledged the statement was inappropriate and indicated that the ADON was counseled for the remark. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, which was not upheld in this instance.
Failure to Report Abuse Allegation Timely
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the California Department of Public Health (CDPH), the State Long Term Care Ombudsman, and local police within the required two-hour timeframe. The incident involved a family member's report that the Assistant Director of Nursing (ADON) made an inappropriate comment to the resident, suggesting they would find peace "six feet under," which was perceived as abusive. The grievance form documenting this allegation was signed by Social Services and the Administrator, but the report was not made to the necessary authorities. Interviews with facility staff revealed a lack of awareness and communication regarding the abuse allegation. The Director of Nursing (DON) was unaware of the abuse claim because he relied on a verbal report from Social Services rather than reviewing the grievance form himself. The Administrator acknowledged reading the grievance form but did not report the incident, as he did not perceive it as abuse, despite the facility's policy requiring all allegations of abuse to be reported immediately. This oversight prevented timely investigation by CDPH and potentially allowed other abuse allegations to go unreported.
Failure to Respond to Alleged Abuse Incident
Penalty
Summary
The facility failed to respond appropriately to an alleged abuse incident involving a resident, as reported by a family member. The incident involved the Assistant Director of Nursing (ADON) making an inappropriate comment to the resident, suggesting they would find peace "six feet under." Despite the seriousness of the allegation, the facility did not take immediate action to assess the resident's physical and psychosocial status, nor did they evaluate whether the resident felt safe. Additionally, the resident's physician was not notified, and the ADON was not removed from access to the resident and other residents. The facility also failed to report the alleged abuse to the California Department of Public Health (CDPH), the State Long Term Care Ombudsman, and local police, as required. The facility did not provide a five-day conclusion of the investigation to the CDPH. Interviews with staff revealed a lack of documentation and follow-up on the incident, including the absence of a detailed report, physical and psychosocial assessments, and updates to the resident's care plan. The Director of Nursing (DON) and the Administrator were unaware of the full extent of the allegations and did not follow the facility's policy and procedure for reporting and investigating abuse. The facility's policy required immediate action to protect residents and ensure that allegations of abuse were reported to the appropriate authorities. However, the Administrator did not submit the necessary reports, and the DON did not initiate the required investigation process. This failure to act according to policy resulted in the inability of the CDPH to determine the validity of the abuse allegation and left the resident and others potentially vulnerable to further abuse.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the California Department of Public Health (CDPH). The resident, who was admitted with severe medical conditions including anoxic brain damage and cardiac arrest, was found to have swelling on the right knee and a right femur fracture. Despite the resident's inability to communicate or make decisions, the facility did not report this unusual occurrence to the CDPH, which is required to rule out potential abuse or neglect. The resident's condition was assessed through various medical evaluations, including a Minimum Data Set (MDS) and x-rays, which confirmed the fracture. Interviews with facility staff, including a Certified Nursing Assistant (CNA), Treatment Nurse (TN), Registered Nurse Supervisor (RNS), and Assistant Director of Nursing (ADON), revealed that the resident required assistance for mobility and had no recorded incidents of falls. Despite these findings, the staff acknowledged that the cause of the fracture was unknown and should have been reported as an injury of unknown origin. The Director of Nursing (DON) admitted to not reporting the injury, mistakenly believing it was not trauma-related. The facility's policies on reporting unusual occurrences and potential abuse were reviewed, indicating that such incidents should be reported within 24 hours. The failure to report the injury as required by state and federal regulations was acknowledged by the DON and other staff members, highlighting a lapse in compliance with established procedures.
Failure to Reassess and Monitor Pain Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically concerning the administration of Percocet. The resident, who was admitted with significant medical conditions including anoxic brain damage and a right femur fracture, was prescribed Percocet for pain management. However, the medication was administered every six hours without proper reassessment of the resident's pain levels, even when assessments indicated a pain level of zero. The facility's records showed that the resident received Percocet regularly despite the absence of pain, as confirmed by the Medication Administration Record (MAR) and interviews with nursing staff. The Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) both acknowledged that the medication was given without parameters for pain levels, and the Interdisciplinary Team Notes did not address the continued use of Percocet. The Assistant Director of Nursing (ADON) also confirmed that no medication regimen review was conducted by the pharmacist, and the medication was administered as a regularly scheduled medicine without reassessment. The facility's policies on pain assessment and medication management were not followed, as ongoing communication between the prescriber and staff was lacking. The failure to reassess and monitor the resident's need for Percocet placed the resident at risk for adverse effects such as respiratory depression and constipation. The facility's policy required the interdisciplinary team to review medication regimens for efficacy and potential problems, which was not adhered to in this case.
Facility Fails to Readmit Resident Post-Hospitalization
Penalty
Summary
The facility failed to readmit a resident after hospitalization, despite the resident being treated and stabilized at a General Acute Care Hospital (GACH). The resident was initially transferred to the hospital due to lethargy and hypotension, and after treatment, the GACH attempted to discharge the resident back to the facility. However, the facility denied readmission, citing a lack of available beds, even though records indicated that beds were available during the relevant period. The resident had been admitted to the facility with diagnoses including acute respiratory failure, sepsis, and dependence on mechanical ventilation. The facility's refusal to readmit the resident was partly justified by the resident's positive test for Carbapenem-resistant Acinetobacter baumannii (CRAB), which the facility claimed required isolation. Despite this, the facility's daily census showed available beds, and the resident was not on isolation at the GACH. Interviews with facility staff, including the Director of Nurses and the Administrator, confirmed the facility's stance of no available beds. However, the facility's policy and procedure indicated that residents should be allowed to return to their previous room if available or to the first available bed. The facility's actions were contrary to the Centers for Medicare & Medicaid Services' guidelines, which state that residents with multidrug-resistant organisms do not require single-person rooms, thus providing no basis for refusal based on the resident's CRAB status.
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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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