Upland Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Upland, California.
- Location
- 1221 E Arrow Hwy, Upland, California 91786
- CMS Provider Number
- 055374
- Inspections on file
- 33
- Latest survey
- September 22, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Upland Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with muscle weakness and mobility issues was not provided with restorative nursing assistance for ambulation after completing physical therapy, despite care plan requirements and recommendations from rehab staff. Staff interviews confirmed that only upper body RNA was performed, and the resident was not assisted with walking, contrary to facility policy.
Surveyors identified that the facility did not maintain required fire sprinkler system records and had an illegible Auxiliary Drain information sign. The Maintenance Director could not provide documentation of the annual sprinkler inspection, and the only available record was from a previous five-year inspection. This deficiency affected all staff and residents in the facility.
Surveyors observed several cigarette butts on the ground in the designated smoking area, and the Maintenance Director was unaware of their presence or duration. This failure to maintain the smoking area in accordance with regulations affected all residents in the facility.
A penetration in the wall beneath a restroom sink in one room created a seven-inch opening, compromising the fire barrier and potentially allowing smoke and gases to pass between areas. The Maintenance Director was unaware of how long the issue had existed, and this deficiency affected 32 residents in one smoke compartment.
A corridor kitchen door equipped with a self-closing device was found not to latch when tested during a facility tour, as confirmed by the Maintenance Director. This deficiency impacted 32 residents in one smoke compartment and resulted in noncompliance with NFPA 101 standards for self-closing doors.
A box of sponge cakes belonging to a housekeeper was found stored in a refrigerator designated for residents' food only, despite clear signage and facility policy prohibiting employee food storage in that area. Staff interviews confirmed the food's ownership and revealed lapses in daily monitoring, resulting in a failure to follow food safety standards and facility policy.
A resident requiring one-on-one meal assistance, with multiple medical conditions, was assisted by a CNA who stood over them during feeding, contrary to both the resident's preference and facility policy. Leadership and facility documents confirmed that staff are expected to be seated at eye level to promote dignity and safe feeding, but this procedure was not followed.
The facility did not consistently provide or document opportunities for residents or their representatives to formulate Advance Directives. In several cases, forms were incomplete, missing, or not followed up, affecting residents with both impaired and intact decision-making capacity. Staff interviews confirmed that required processes for offering and recording Advance Directive information were not reliably implemented.
A resident with chronic respiratory failure received PRN clonazepam for anxiety, and the order was extended beyond the initial period without documented rationale from the prescriber in the medical record. The DON confirmed that this extension lacked the required documentation, which did not comply with facility policy on psychoactive drug monitoring.
A resident admitted for orthopedic aftercare following a left below-the-knee amputation was discharged without the required advance notification to the State LTC Ombudsman. The facility's policy and federal regulations require that the Ombudsman be notified at least 30 days before discharge, but staff confirmed the notification was sent after the resident had already left. Both the DON and Administrator acknowledged the failure to meet the notification timeframe.
Three residents did not have appropriate individualized care plans developed or implemented for their specific needs, including anticoagulant medication management and dental care. One resident on apixaban lacked a care plan for anticoagulant use, another resident with lost dentures and dental issues had no dental care plan, and a third resident on Lovenox did not have care plan interventions for monitoring bruising implemented after a fall. Staff confirmed the absence or lack of implementation of these care plans.
A resident with functional quadriplegia, fully dependent on staff for personal hygiene, was found with untrimmed and dirty fingernails. Staff acknowledged that nail care was not provided as required by facility policy, which mandates daily cleaning and regular trimming during ADL care. The DON confirmed that the facility's expectations and procedures for grooming were not followed.
A resident with MASD on the buttocks did not receive consistent weekly wound assessments as required by facility policy, despite ongoing physician-ordered treatment. Nursing staff confirmed missing documentation for two weeks, which is necessary to monitor wound progression and guide care.
A resident with obstructive sleep apnea who used a CPAP machine nightly did not have the machine's filter replaced according to manufacturer guidelines. Staff observed the filter was discolored and could not identify who was responsible for its maintenance. There was no documentation of filter inspection or replacement, despite the manufacturer's recommendation for regular checks and changes.
A resident with end stage renal disease who received regular dialysis had a bandage left on their dialysis access site for more than four hours after treatment, contrary to facility policy. Both an LVN and the DON observed the bandage the morning after dialysis, and records confirmed it should have been removed within three to four hours as part of post-dialysis care.
A resident with contractures and impaired upper extremity mobility was assessed as able to use bed rails for mobility, despite being fully dependent on staff and unable to utilize the rails. Documentation and staff interviews confirmed inconsistencies between the resident's actual abilities and the bed rail assessment, resulting in improper use of side rails.
A resident with chronic heart failure and on dialysis did not receive a prescribed dose of furosemide after an LVN withheld the medication due to an unclear order to hold all blood pressure meds on dialysis days. The nurse did not clarify whether the diuretic, ordered for heart failure, should be held, resulting in a missed dose. The DON confirmed that facility policy requires clarification of any questionable orders.
Surveyors identified that medications in one medication room were stored at temperatures exceeding manufacturer recommendations, with the room temperature recorded at 78°F on two days. Multiple medications requiring storage at or below 77°F were found in this room, and both the ADON and DON acknowledged the facility's policy to follow manufacturer guidelines for medication storage.
A resident with osteoarthritis and a history of stroke had physician orders for daily RNA services for ambulation, but documentation was incomplete, with only a few entries in one month and none in the following month. The RNA and DON confirmed that services provided or refused should have been documented, and facility policy requires complete documentation of care.
A single-dose acetic acid container was not discarded after opening and was stored in a treatment cart for several days, contrary to manufacturer instructions and facility policy. Additionally, a non-laundry staff member entered the clean area of the laundry department and removed clean linens, despite facility protocols restricting this area to laundry staff only. Both actions were inconsistent with infection control procedures.
A resident with limited mobility was left uncovered in bed by a CNA, violating privacy standards. Another CNA delayed attending to the resident for a change, failing to request assistance. These actions did not adhere to the facility's policy on resident dignity and timely care.
A LTC facility failed to provide a resident's medical records to their legal representative after a written request. The resident, with multiple health conditions, had a legal representative who claimed to have successfully faxed a request for the records. However, the facility's staff denied receiving the fax until a follow-up call was made. This failure potentially violated the resident's rights to access their medical records.
A resident's dignity and rights were compromised when an LVN entered her room without permission and removed her oxygen tubing, mistaking it for another resident's. The resident, who was cognitively intact and required assistance for daily activities, was left confused and upset. The facility's policy on resident rights, emphasizing respect and dignity, was not followed, as confirmed by the DON.
A resident with multiple serious health conditions developed an unstageable pressure ulcer on the coccyx and left buttocks while in the facility. Despite being assessed as high risk for pressure sores, preventive measures such as turning and repositioning and the use of a low air loss mattress were implemented only after the ulcer developed. The facility's failure to prevent the pressure ulcer placed the resident's health and safety at risk.
A resident with limited mobility was not provided a bedside commode or assisted to the bathroom, despite the facility's policy to assess and assist residents with toileting needs. This failure potentially impacted the resident's dignity and psychological well-being.
Failure to Provide Restorative Ambulation Services After PT Discharge
Penalty
Summary
A resident with diagnoses including muscle weakness, type 2 diabetes, hypertension, and gait abnormalities was admitted to the facility and required assistance to maintain or improve mobility. The resident's care plan indicated a need to improve functional mobility and reduce fall risk, with interventions to address limited physical mobility. After the resident completed physical therapy, facility staff failed to continue restorative nursing assistance (RNA) exercises for ambulation, despite the care plan and recommendations from the rehab staff that the resident should have been placed on an RNA program for walking. Observations and interviews revealed that the resident remained in bed and only received RNA for the upper body, with no ambulation exercises provided. The CNA and LVN confirmed the resident stayed in her room and had not been observed walking, while the restorative nursing assistant stated that only upper body RNA was performed. The facility administrator acknowledged that there was no continuation of therapy for RNA after physical therapy ended, and the resident was not placed on the RNA program for ambulation as required by facility policy.
Failure to Maintain and Document Fire Sprinkler System Inspections
Penalty
Summary
The facility failed to maintain the automatic fire sprinkler system in accordance with regulatory requirements. During a document review and interview, surveyors found that the Auxiliary Drain information sign located on the west outside wall near the generator was faded and illegible. The Maintenance Director stated that the contractor responsible for replacing sprinkler system signs during the semi-annual inspection had been informed about the need for replacement approximately two months prior, but the sign had not yet been replaced. Additionally, the facility was unable to provide records of the required annual sprinkler system inspection and testing. The only documentation available was from a five-year sprinkler inspection/test conducted previously. The Maintenance Director indicated that the facility was under contract with a sprinkler company that was supposed to conduct annual inspections automatically, but no records for the most recent annual inspection could be located. This deficiency affected all staff and all 192 residents across six smoke compartments.
Plan Of Correction
K353 NFPA 101 Sprinkler System - Maintenance and Testing How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: The automatic fire sprinkler system inspection and testing was immediately scheduled and completed on 5/27/25. The auxiliary Drain Information sign was replaced on 5/27/25. No residents were affected by the finding. The automatic fire sprinkler system inspection and testing was immediately scheduled and completed on 5/27/25. The auxiliary Drain Information sign was replaced on 5/27/25. No residents were affected by the finding. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: All residents have the potential to have been affected by this finding. Maintenance director completed audit to ensure all inspections and testing are up to date. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: Maintenance staff were in serviced on 5/27/25 by the Administrator regarding policy on ensuring that all sprinkler inspections and testing are completed to ensure compliance. Maintenance director will ensure that all logs are reviewed monthly for the next 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: The Administrator or designee will review inspection and testing records for the next 3 months to monitor for compliance. Any issues will be reported to the Quality Assurance committee for review and recommendations. Completion date of corrective actions: June 9, 2025. K 353
Failure to Maintain Smoking Area Cleanliness
Penalty
Summary
During a facility tour and interview with the Maintenance Director, surveyors observed approximately five cigarette butts on the ground near the designated smoking area. The Maintenance Director stated that he was unaware of the cigarette butts being present and did not know how long they had been there. This observation indicated that the facility failed to properly maintain the smoking area as required by regulations, specifically regarding the disposal of cigarette butts. The deficiency affected all 192 residents across six smoke compartments. No information was provided regarding the medical history or condition of any specific residents at the time of the deficiency.
Plan Of Correction
K741 NFPA 101 Smoking Regulations How corrective action will be accomplished for those residents found to have been affected by the identified practice: All cigarette butts were immediately picked up from the smoking area ground. No residents were affected by the finding. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: All residents have the potential to have been affected by the practice. Housekeeping staff will ensure that all smoking areas are cleaned daily, ash trays are emptied out, and any cigarette butts are picked up daily. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: Housekeeping staff were in serviced on 5/27/25 by the Administrator regarding keeping smoking areas free of smoking debris on the floor. Housekeeping supervisor or designee will check smoking areas to ensure compliance weekly for the next 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: The Administrator or Designee will do rounds weekly and for the next 3 months to monitor for compliance. Any issues will be reported to the Quality Assurance committee for review and recommendations. Completion date of corrective actions: Імие 9, 2025.
Unsealed Wall Penetration Compromises Fire Barrier
Penalty
Summary
During a facility tour and interview with the Maintenance Director, surveyors observed a deficiency related to the building's construction. Specifically, in Room 203, there was a drain cap underneath the restroom sink that was not flush with the wall, resulting in an approximately seven-inch crescent-shaped penetration. This opening was identified as a potential pathway for smoke and gases to travel between different parts of the building, which is not in compliance with fire safety requirements for health care occupancies. The Maintenance Director was interviewed at the time of the observation and stated that he was unsure how long the penetration had been present. This deficiency affected 32 out of 192 residents in one of the six smoke compartments within the facility. The report does not provide additional details about the specific medical history or condition of the residents affected at the time of the deficiency.
Plan Of Correction
The following Plan of Correction is submitted by the facility in accordance with the pertinent terms and provisions of 42 CFR Section 488 and/or related state regulations and is intended to serve as a credible allegation of our intent to correct the practices identified as deficient. The Plan of correction should not be construed or interpreted as an admission that the deficiencies alleged did, in fact, exist; rather, the facility is submitting this document in order to comply with its obligations as a provider participating in Medicare/Medicaid program(s). K161 NFPA 101 Building Construction type and height. How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: The Penetration in Room 203 was immediately fixed. No residents were affected by this finding. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken. All residents have the potential to have been affected by the practice. Maintenance director and assistant checked all other drain caps in all restrooms and no issues were identified. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur. Maintenance Staff were in serviced on June 2, 2025 by administrator regarding the policy penetrations in the facility. Maintenance Director or designee will check all storage rooms and hallways to ensure there are no penetrations weekly for the next 3 months. Dept heads or designee will check their Guardian Angel rooms weekly for any penetrations for the next 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator or designee will do rounds weekly for the next 3 months to monitor for compliance. Any issues will be reported to the Quality Assurance committee for review and recommendations. Completion date of corrective actions: June 9, 2025. K 161
Failure to Maintain Self-Closing Door Latching Mechanism
Penalty
Summary
During a facility tour and interview with the Maintenance Director, it was observed that a corridor kitchen door equipped with a self-closing device did not latch when tested. The Maintenance Director acknowledged at the time of observation that he had just realized the door was not latching. This deficiency affected 32 out of 192 residents in one of six smoke compartments. The report documents that the door's failure to latch could allow the passage of smoke and gases from one part of the building to another, as the door was not maintained in accordance with NFPA 101 requirements for self-closing devices.
Plan Of Correction
K223 NFPA 101 Doors with self-closing devices How corrective action will be accomplished for those residents found to have been affected by the identified practice: Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: The door with self-closing device that did not latch when released was immediately fixed by maintenance staff. No residents were affected by the finding. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: All residents have the potential to be affected by this practice. Maintenance director and assistant conducted a sweep of all self-closing doors to ensure they latch upon release. No other findings identified. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: Maintenance staff were in serviced on June 2, 2025 by the administrator regarding policy on self-closing devices. Maintenance Director or Designee will check all self-closing devices biweekly to ensure compliance for the next 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained: The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator or Designee will do rounds monthly for the next 3 months to monitor for compliance. Any issues will be reported to the Quality Assurance committee for review and recommendations. Completion date of corrective actions: June 9, 2025
Employee Food Improperly Stored in Residents' Refrigerator
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety when an employee's food was found inside a refrigerator designated for residents' food only. During an observation, a box of sponge cakes labeled with a name and date was discovered in the residents' refrigerator on Station 1, which had signage indicating it was for residents' food only and not for employee use. Staff interviews revealed uncertainty about the ownership of the food, and it was later confirmed that the food belonged to a housekeeper working at night. The administrator acknowledged that staff should not have placed their food in the residents' refrigerator and that the facility's policy required daily monitoring of these refrigerators by designated staff. A review of facility records showed that Station 1 had 56 residents, with 50 on oral diets, making them potentially susceptible to cross-contamination from improper food storage. The facility's policy on resident/personal food storage required monitoring for food safety, but this policy was not followed in this instance. The FDA Food Code was also referenced, indicating that ready-to-eat food potentially contaminated by an employee should be discarded. The failure to adhere to these standards and policies resulted in a deficiency related to food storage and safety.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
A deficiency was identified when a Certified Nurse Assistant (CNA) failed to treat a resident with dignity during a meal. The resident, who had diagnoses including unstable angina, atherosclerosis, hypertension, and diabetes, required one-on-one assistance during meals. During an observation, the CNA was seen standing over the resident while assisting with feeding, despite the resident expressing a preference for the CNA to be seated. The CNA acknowledged that the correct procedure was to be seated facing the resident during feeding. Further interviews with facility leadership confirmed that the expectation and facility policy required CNAs to be seated at eye level with residents during feeding to promote dignity and ensure safe feeding practices. Review of the facility's feeding techniques document also specified that staff should never stand above or lean over residents while feeding them. The Director of Nursing confirmed that the CNA did not follow the facility's established procedure in this instance.
Failure to Document and Offer Advance Directives to Residents
Penalty
Summary
The facility failed to honor residents' rights to formulate Advance Directives for five sampled residents. For three residents, the Advance Directives Checklist forms did not indicate whether they were provided an opportunity to formulate an Advance Directive. Specifically, one resident's form acknowledged receipt of information but did not document whether the resident wished to formulate an Advance Directive, and the resident reported not being offered assistance. Another resident's form was incomplete, with unchecked boxes and a responsible party who was unsure what an Advance Directive was or if it had been offered. A third resident's form was undated, unsigned, and did not indicate whether the responsible party was provided with information, despite the resident being severely cognitively impaired and unable to follow commands. For another resident with severe cognitive impairment and no decision-making capacity, the Advance Directives Checklist was faxed to the responsible party for signature, but the form remained unsigned and there was no documentation that the responsible party received the information or was given the opportunity to complete the Advance Directive. In the case of a fifth resident, who had full decision-making capacity, there was no Advance Directives Checklist in the medical record, and the POLST form was incomplete regarding the Advance Directive section. Interviews with facility staff, including the Director of Social Services and the Director of Nursing, confirmed that the process for providing and documenting Advance Directive information was not consistently followed. The facility's policy required that residents or their representatives be provided with written information about Advance Directives upon admission and that this be documented in the health record, but this was not done for the affected residents.
Lack of Documentation for Extended PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the medical record contained documentation demonstrating the rationale for extending a PRN (as needed) psychotropic medication order for a resident. Specifically, a resident with chronic respiratory failure had a PRN order for hydroxyzine for anxiety, which was later changed to a scheduled dose, and subsequently, clonazepam was started as a PRN medication for anxiety. The clonazepam PRN order was extended beyond the initial 14-day period without documentation from the prescribing practitioner explaining the medical necessity for this extension in the resident's medical record. Review of the resident's records showed that the medication was administered as ordered, and observations confirmed the resident was sleeping after receiving the medication. During interviews and record reviews with the DON, it was acknowledged that the required documentation for the rationale behind the continued PRN use of clonazepam was missing, which was not in accordance with the facility's own policy on psychoactive drug monitoring. The policy requires that the medical necessity for psychoactive medications be documented and regularly reassessed, with any continuation clearly indicated in the medical record.
Failure to Notify Ombudsman Prior to Resident Discharge
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman prior to the discharge of a resident who had been admitted for orthopedic aftercare following a left below-the-knee amputation. The resident was determined to have the capacity to understand and make decisions. According to the facility's own policy and federal requirements, the Ombudsman should be notified at least 30 days before a resident is transferred or discharged, or as soon as practicable before the event. Record review and staff interviews revealed that the Notice of Proposed Transfer/Discharge for the resident was faxed to the Ombudsman's office after the resident had already been discharged. The Director of Social Services confirmed the late notification, and both the Director of Nursing and the Administrator acknowledged that the required notification timeframe was not met. The facility's policy was reviewed and found to be consistent with the regulatory requirement for advance notification.
Failure to Develop and Implement Individualized Care Plans for Medication and Dental Needs
Penalty
Summary
The facility failed to develop and implement individualized care plans for three residents, resulting in deficiencies related to medication management and dental care. For one resident with atrial fibrillation who was prescribed apixaban, there was no care plan developed to address the use of this anticoagulant, despite documentation confirming the medication was being administered as ordered. Staff interviews confirmed the absence of a care plan and acknowledged the necessity of such a plan to guide monitoring and care. Another resident, who was cognitively intact and had both upper and lower dentures upon admission, experienced the loss of their dentures while at the facility. Despite dental assessments, recommendations for tooth extraction, and ongoing issues with eating and appearance, there was no care plan developed to address the resident's dental care needs. Staff and social services confirmed awareness of the dental issues and the lack of a corresponding care plan. A third resident, with a history of stroke and on anticoagulant therapy (Lovenox), had a care plan that included interventions for daily skin inspections and monitoring for complications such as bruising. However, after the resident sustained a fall and developed bruising, there was no evidence that the care plan interventions were implemented, as required. The DON confirmed that the resident's bruising should have been monitored according to the care plan, but this was not documented or carried out.
Failure to Provide Proper Nail Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with functional quadriplegia, who was dependent on staff for personal hygiene, was observed with untrimmed and dirty fingernails on the right hand. The resident's Admission Record indicated a diagnosis of functional quadriplegia, and the Minimum Data Set confirmed functional limitations in both upper and lower extremities, requiring staff assistance for personal hygiene. During an observation, the resident's fingernails were found to be untrimmed and dirty, and a Certified Nurse Assistant acknowledged that the nails should have been trimmed and clean, in accordance with facility expectations. A review of the facility's policy and procedure for nail care revealed that daily cleaning and regular trimming of nails during activities of daily living (ADL) care were required to prevent infections and skin problems. The Director of Nursing confirmed that the facility's policy was not followed in this instance and that the expectation for grooming services for the resident was not met.
Failure to Consistently Assess and Document Wound Care
Penalty
Summary
The facility failed to provide consistent wound assessments for a resident with moisture-associated skin damage (MASD) on the buttocks, as required by the facility's policy and procedure. The resident, who had a history of peripheral vascular disease and chronic obstructive pulmonary disease, was admitted with a physician's order for daily wound care and a reevaluation after 21 days. However, a review of the medical record revealed that there were no documented assessments of the wound for two consecutive weeks, despite the ongoing treatment. During interviews and record reviews, a licensed vocational nurse confirmed the absence of wound assessment documentation for the specified weeks and acknowledged the importance of such documentation in guiding care and monitoring the wound's progress. Observations confirmed the presence of scattered areas of skin redness and shallow open areas on the resident's buttocks. The facility's policy required weekly head-to-toe assessments by licensed nursing staff, which were not completed as documented for the resident during the identified period.
Failure to Replace CPAP Filter According to Manufacturer Guidelines
Penalty
Summary
The facility failed to provide appropriate respiratory care services for one resident with obstructive sleep apnea who required nightly use of a CPAP machine. The resident's care plan and physician's order specified the use of the CPAP machine at bedtime. During multiple observations and interviews, it was found that the filter in the resident's CPAP machine was discolored, appearing light grey and dark grey, rather than the white color of a new filter. Staff, including a licensed vocational nurse, the assistant director of nursing, and the respiratory therapy supervisor, acknowledged the filter's condition and were unsure who was responsible for checking or replacing it. A review of the manufacturer's user guide indicated that the CPAP filter should be checked and replaced at least every six months, or more frequently if dirty or blocked. However, there was no documentation that the filter had been inspected or changed for this resident. The director of nursing confirmed that nursing staff were responsible for ensuring the CPAP machine was functioning and that the respiratory department was responsible for settings, but acknowledged the facility did not follow the manufacturer's guidelines for filter replacement.
Failure to Timely Remove Dialysis Site Bandage
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease, who required regular dialysis treatments, was found to have a bandage left on their dialysis access site for more than four hours after returning from dialysis. The resident was admitted with a diagnosis of irreversible kidney failure and had physician orders for dialysis three times a week. On the morning following a dialysis session, a bandage was observed on the resident's left arm by both an LVN and the DON. Upon review, it was confirmed that the bandage had been in place since the previous day's dialysis treatment. Facility records, including the Facility/Dialysis Center Nursing Communication Record and the facility's inservice lesson plan, indicated that post-dialysis care required bandages to be removed within three to four hours after treatment. The DON acknowledged that the bandage should have been removed within this timeframe, but it remained on the resident's arm for longer, contrary to facility policy and best practices for post-dialysis care.
Inaccurate Bed Rail Assessment and Use for Dependent Resident
Penalty
Summary
The facility failed to ensure that the bed rail assessment for a resident with significant functional limitations was accurate and that the use of side rails was appropriately indicated. The resident in question had contractures and impaired range of motion in both upper extremities, as documented in multiple assessments, including the Minimum Data Set and Occupational Therapy evaluation. Despite these limitations, a physician's order and a Bed Rail Safety Evaluation indicated that side rails were to be used to aid in bed mobility, and the evaluation inaccurately stated that the resident could move freely in bed without signs of impaired mobility. Observations and staff interviews confirmed that the resident was dependent on staff for all mobility and activities of daily living, and was unable to use the side rails due to contractures. During care, the resident did not reach for or hold onto the side rail when prompted, and staff acknowledged the resident's inability to use the rails. The Director of Rehabilitation Services also confirmed that the side rails could not aid the resident's mobility due to the functional limitations. The facility's policy required ongoing assessment to ensure bed rails met the resident's needs, but this was not accurately reflected in the resident's documentation or practice.
Failure to Clarify Medication Orders Leads to Missed Dose
Penalty
Summary
The facility failed to ensure safe and effective pharmaceutical services for a resident with a history of chronic congestive heart failure, hypertension, and dependence on renal dialysis. The resident had a physician's order for furosemide, a diuretic, to be administered twice daily for congestive heart failure. A subsequent order instructed staff to hold all blood pressure medications on the morning of dialysis days. However, the furosemide, which was prescribed for heart failure and not specifically for blood pressure, was withheld by the nurse on a dialysis day without clarifying the order with the physician. During interviews and record reviews, the nurse acknowledged that the furosemide was categorized as a diuretic and not a blood pressure medication, and that the two orders should have been clarified to avoid confusion. The Director of Nursing confirmed that facility policy requires verification of any order that appears inappropriate considering the resident's condition or diagnosis. The failure to clarify the medication orders resulted in the resident not receiving the prescribed furosemide dose as intended.
Medications Stored Above Manufacturer-Recommended Temperature
Penalty
Summary
Surveyors found that the facility failed to store medications at the appropriate temperature in one of three medication rooms, specifically the Station 2 Medication Room. The daily temperature log showed that the room temperature reached 78°F on two consecutive days, exceeding the maximum storage temperature of 77°F indicated on the product labeling for several medications. During an inspection, multiple medications, including acetaminophen, senna syrup, loperamide, and docusate sodium, were observed stored in this room. The Assistant Director of Nursing confirmed that the product labels required storage at or below 77°F. A review of the facility's policy on medication storage, approved in January 2025, stated that medications and biologicals must be stored safely and according to manufacturer recommendations. The Director of Nursing acknowledged this policy during the interview and record review. The failure to maintain the required storage temperature for these medications constituted a deficiency in following both manufacturer guidelines and facility policy.
Failure to Document Restorative Nursing Services
Penalty
Summary
The facility failed to ensure complete and accurate documentation of Restorative Nursing Assistant (RNA) services for one resident. The resident, who had diagnoses including osteoarthritis in both knees and a history of stroke, was admitted with physician orders specifying RNA services for ambulation with a front wheel walker five times a week. Review of the resident's medical record showed only four RNA entries for March and no entries for April, despite the ongoing order for daily services on weekdays. During an interview and record review, the RNA stated that documentation should be completed after providing or attempting RNA services, including noting if the resident refused. The Director of Nursing confirmed the absence of documentation for RNA services from March 9 through the end of April. Facility policies reviewed indicated that appropriate documentation is required to address program goals and resident tolerance, as well as to provide a complete account of care and treatment.
Failure to Discard Single-Dose Acetic Acid and Unauthorized Access to Clean Laundry Area
Penalty
Summary
The facility failed to implement proper infection prevention and control measures in two distinct situations. In the first instance, a single-dose container of acetic acid, used to prevent blockage in tubes connected to residents, was not discarded after being opened. The container was labeled with the date it was opened and was found stored in a treatment cart several days later. Interviews with the LVN, DON, and Infection Preventionist confirmed that the acetic acid was a single-dose, preservative-free solution, and manufacturer instructions required prompt use and immediate disposal of any unused portion. Facility policy also required medications to be stored and handled according to manufacturer recommendations, which was not followed in this case. In the second situation, a non-laundry staff member entered the restricted clean area of the laundry department and removed clean linens from a linen cart. Observations and interviews with the Environmental Services Supervisor, Infection Preventionist, and DON confirmed that only laundry staff were permitted to handle clean linens in the clean area, and non-laundry staff were required to remain outside this area. Facility policies on infection prevention and laundry services emphasized the importance of restricting access and handling of clean linens to prevent the spread of infection. Both deficiencies were identified through direct observation, staff interviews, and review of facility policies and manufacturer instructions. The actions taken by staff in both cases were inconsistent with established infection control protocols and facility procedures, leading to the cited deficiencies.
Failure to Ensure Resident Privacy and Timely Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident who was admitted with diagnoses including an internal right hip prosthesis, heart failure, and hypertension. The resident's care plan emphasized the need for privacy to promote dignity. However, a Certified Nursing Assistant (CNA 1) left the resident naked and uncovered in bed with the curtain halfway open, failing to ensure privacy as required by the care plan. This action was acknowledged by CNA 1, who admitted to forgetting to cover the resident with a sheet before leaving the room. Additionally, another CNA (CNA 2) took an extended period to attend to the resident for a change. During an interview, CNA 2 mentioned being occupied with other residents, which delayed attending to the resident's needs. The Director of Nursing (DON) indicated that CNA 2 should have requested assistance to ensure timely care. Both instances were noted as failures to adhere to the facility's policy and procedure, which mandates treating residents with respect and dignity.
Failure to Provide Medical Records Upon Request
Penalty
Summary
The facility failed to provide a resident or their legal representative with a copy of medical records following a written request. This deficiency was identified for one of the three residents reviewed for resident rights. The resident in question was admitted to the facility with multiple diagnoses, including sepsis, urinary tract infection, generalized muscle weakness, type 2 diabetes mellitus, and dementia. The legal representative of the resident claimed to have sent a fax request for the medical records, with a successful transmission confirmation, but the facility's Medical Record Director (MRD) denied receiving such a request. Interviews with the MRD and the Administrator revealed that the facility did not acknowledge receiving the faxed request on the date specified by the legal representative. The facility's policy requires a 48-hour notice for such requests, excluding weekends and holidays. Despite the legal representative's confirmation of the fax transmission, the facility maintained that they did not receive the request until a later date, when a follow-up phone call was made by the legal representative's law office. The facility's failure to provide the requested medical records within the stipulated time frame potentially violated the resident's rights.
Failure to Respect Resident's Dignity and Rights
Penalty
Summary
The facility failed to treat a resident with dignity and respect when a staff member entered the resident's room and removed her oxygen tubing without permission. The incident involved a resident who was cognitively intact and required maximal assistance for daily living activities. The resident had been admitted with diagnoses including heart failure, Type 2 diabetes mellitus, and hypertension. On the day of the incident, a Licensed Vocational Nurse (LVN) entered the room without announcing herself and mistakenly removed the resident's oxygen tubing, assuming it belonged to another resident. This action was taken without verifying the ownership of the oxygen concentrator or explaining the action to the resident. The resident was left confused and upset by the removal of her oxygen tubing, which was reported to the facility administrator the following day. The resident's daughter also reported the incident, and the resident expressed her distress to a Certified Nursing Assistant (CNA) who assisted her afterward. The Director of Nursing (DON) confirmed that the facility's policy on resident rights, which emphasizes respect and dignity, was not followed in this instance. The failure to adhere to these policies compromised the resident's dignity and violated her rights.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide adequate care to prevent the development of a pressure ulcer in a resident who was admitted with multiple serious health conditions, including metabolic encephalopathy, acute respiratory failure, and acute kidney failure. Upon admission, the resident had scar tissue on the coccyx and unstageable tissue depth blisters on the heels, but no open wounds. The resident was assessed as high risk for pressure sores, with a Braden Scale score of 7. Despite this, the resident developed an unstageable pressure ulcer on the coccyx and left buttocks while in the facility. The facility's records indicate that the resident was initially observed with moisture-associated skin damage to the buttocks, and interventions such as turning and repositioning every two hours and the use of a low air loss mattress were ordered. However, these measures were implemented after the pressure ulcer had already developed. Interviews with the treatment nurse and the DON revealed that the resident's fragile condition and comorbidities contributed to the development of the ulcer, but the facility's policy required preventive measures to be in place to avoid such occurrences. The facility's failure to prevent the pressure ulcer placed the resident's health and safety at risk.
Failure to Accommodate Resident's Toileting Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, identified as Resident 1, by not providing a bedside commode and not assisting the resident to the bathroom for toileting. This deficiency was identified during a review of Resident 1's admission record and care plan, which indicated a self-care performance deficit related to limited mobility. The care plan aimed for the resident to perform activities of daily living with modified independence, including toilet use, while promoting dignity and ensuring privacy. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) revealed that the facility's usual practice is to assess residents upon admission for their ability to transfer and to assist them to the bathroom upon request. The facility's policy and procedure for admission, transfer, and discharge rights outlined the objectives to admit residents who can be adequately cared for by the facility. However, the failure to provide the necessary toileting assistance and equipment for Resident 1 had the potential to impact the resident's psychological well-being by affecting their respect and dignity.
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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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