Vineyard Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Petaluma, California.
- Location
- 101 Monroe Street, Petaluma, California 94954
- CMS Provider Number
- 555120
- Inspections on file
- 42
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Vineyard Post Acute during CMS and state inspections, most recent first.
Licensed nurses failed to notify a resident’s representative of two significant changes in condition: an elopement and a subsequent fever. The resident had severe cognitive impairment, was deemed unable to make his own health decisions, and had a Wanderguard order for exit-seeking behavior. After the resident left the building and was returned by police, there was no documentation that the representative was informed. Later, when the resident developed a fever with respiratory symptoms and the MD was notified and treatment given, there was again no documentation of representative notification. The DON confirmed expectations and facility policies required notifying the resident’s representative and documenting these contacts, and one nurse admitted she did not know she had to report the fever.
A resident with dementia, severe cognitive impairment, atrial flutter on anticoagulation, and a history of repeated falls was assessed as high risk for wandering and elopement and had care plans and orders for close supervision and use of a Wanderguard device. Despite these measures, the resident eloped during early morning hours, leaving the building unnoticed, walking off premises to a nearby baseball field, and crossing a neighborhood intersection before being returned by police. Documentation indicated the Wanderguard was in place but did not alarm, the care plan for elopement had not been updated after the incident, and key staff, including the AD and HRD, were unclear about monitoring and replacement of the Wanderguard, while the Maintenance Director could not explain how the resident exited without triggering the door alarm.
Surveyors observed a medication cart left unlocked and unattended in a hallway outside a resident room. The NS locked the cart and stated that carts must always be locked when unattended so unauthorized individuals, including residents, cannot access medications. An RN responsible for the cart admitted leaving it unlocked and unattended, acknowledging that this violated facility policy requiring carts to be locked when not in use. The DON confirmed that only nurses are authorized to access medications and that leaving a cart unlocked while unattended is a safety issue, consistent with the written medication administration policy requiring carts to remain visible to staff and inaccessible to residents or passersby.
A resident with chronic kidney disease and a recent leg fracture had weekly CBC and BMP labs ordered, but one scheduled lab draw was documented as completed on the eMAR without any evidence in the EMR that it was actually obtained. Later, labs that were drawn showed flagged abnormalities in WBC, BUN, creatinine, and BUN/CREAT ratio, yet no SBAR was initiated and there was no documentation that the MD was notified of these abnormal results. Subsequent SBARs addressed edema, decreased urine output, abdominal pain, and urinary retention, and the resident was later sent to the ER with severe back pain and was found to have markedly elevated BUN and creatinine with diagnoses including UTI, AKI, and dehydration. Facility policies and staff interviews confirmed that ordered labs were to be obtained, abnormal results promptly reported to the MD, and changes in condition documented, which did not occur as required in this case.
A resident recovering from digestive system surgery experienced ongoing moderate to severe pain after nursing staff failed to administer physician-ordered morphine sulfate, instead providing only acetaminophen intended for mild pain. Despite documented increases in pain and minimal relief from acetaminophen, staff did not notify the physician or follow up on the morphine order, resulting in the resident enduring severe pain until hospitalization. The facility's policies for pain assessment and medication administration were not followed.
A resident with diabetes did not have sliding scale or blood sugar parameter orders for insulin administration, and staff failed to check blood glucose prior to giving insulin. This led to a hypoglycemic episode requiring hospitalization. Staff and the DON confirmed that required orders and monitoring were not in place before the incident.
A resident recovering from a stroke was unable to get uninterrupted sleep due to another resident's constant yelling and aggressive behavior. Despite notifications to the DON, the disruptive behavior persisted, affecting the homelike environment. Staff and other residents confirmed the ongoing issue, suggesting the facility might not be suitable for the disruptive resident's care needs.
The facility did not report an influenza outbreak to the LPHD for nearly three weeks, affecting 28 residents and staff. The outbreak began when two residents tested positive, and the IP, who was responsible for reporting, was away. The DON, DSD, and ADM all assumed others were responsible for notifying the LPHD, leading to a delay. The facility's policy required immediate reporting, but this was not followed, preventing the LPHD from providing necessary support.
A resident with a history of respiratory failure was found unresponsive and pulseless, but facility staff failed to initiate CPR promptly. Despite low oxygen saturation and the presence of an AED, CPR was not started until paramedics arrived, leading to the resident's death. Interviews revealed staff confusion about when to begin CPR.
A resident with severe cognitive impairment wandered into another resident's room, leading to a physical altercation. The second resident, feeling threatened, head-butted and restrained the first resident, resulting in a small injury. The facility's policy on abuse prevention was not upheld.
A resident with end-stage renal disease missed scheduled medications on dialysis days, and the facility failed to notify the physician. The resident's MAR showed multiple instances of missed doses, and staff interviews revealed inconsistent communication with the physician. The DON and Administrator acknowledged the need for physician notification when medications are not administered.
A resident with ESRD in a facility experienced significant medication errors, particularly on dialysis days. Critical medications for low blood pressure, atrial fibrillation, blood clot prevention, and diabetes were often not administered as scheduled. Staff interviews revealed inconsistent communication and adherence to protocols, with medications either not given or administered outside prescribed parameters.
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in the PASARR process. One resident with schizoaffective disorder and dementia, and another with psychosis and major depressive disorder, were not accurately represented in their MDS, missing their positive PASARR status for serious mental illness. Interviews revealed the MDS Coordinator overlooked this information, and the Administrator and DON acknowledged the assessments should have been accurate.
A resident with COPD and heart failure had a physician's order for 2L/min supplemental oxygen, but observations revealed the oxygen concentrator was set at 3.5L/min. The resident confirmed the correct setting should be 2L/min. An RN acknowledged the error and adjusted the setting, while the DON and attending physician confirmed the need to adhere to the prescribed oxygen level.
A resident with a history of allergic rhinitis, chronic pain, and COPD was found with multiple medications improperly stored in their room, contrary to facility policy. Despite having intact cognition, the resident self-administered some medications without informing staff. Interviews with staff confirmed that residents need an order to keep medications at the bedside, which was not in place for this resident.
A resident with a history of CHF and muscle weakness did not receive occupational therapy as ordered, due to staffing challenges. The resident was supposed to receive therapy three times a week, but only received it on three occasions over two months. Staff interviews confirmed the deficiency and the expectation for therapy to be provided as ordered.
A resident with diabetes and peripheral vascular disease experienced severe complications due to the facility's failure to provide timely foot care and communication. Nursing staff did not document daily skin assessments, leading to the resident's necrotic toe going unnoticed for a month. Miscommunication with the physician delayed appropriate intervention, and the facility delayed the resident's hospital transfer, resulting in sepsis and toe amputation.
A resident with PTSD threw water on another resident due to being disturbed by her continuous screaming, leading to the affected resident feeling unsafe. Both residents were cognitively intact, and the incident was confirmed by an LPN who found the affected resident's belongings damp. The facility's policy on abuse prevention was not upheld.
A resident with metastatic breast cancer was discharged from an LTC facility without her prescribed opioid medications, leading to severe pain and opiate withdrawal. The discharge process was rushed and unprepared, resulting in incomplete documentation and failure to provide necessary medications. The facility's policy lacked procedures for non-emergent discharges and medication provision.
A resident identified as a high fall risk fell from his wheelchair at the nurses' station, resulting in a bruise and hospital evaluation. Despite a fall risk assessment, no fall prevention care plan was developed. Staff interviews revealed the resident was agitated, and the facility's policy on managing fall risks was not followed, contributing to the incident.
A resident in a LTC facility did not receive his pain medication in a timely manner, leading him to feel helpless and unimportant. The delay occurred during a shift change, and the resident expressed feeling unsafe as staff seemed to prioritize their shift over patient needs. The resident was cognitively intact and on a scheduled pain medication regimen. A nurse acknowledged the importance of treating residents with respect and dignity, but the facility's policy was not followed in this instance.
The facility failed to administer scheduled medications within the required time frames for three residents, leading to delays of up to three hours. Despite the policy requiring administration within one hour of the scheduled time, multiple medications were given late. The DON acknowledged awareness of the time frame but did not routinely audit medication pass times, contributing to the issue.
Failure to Notify Resident Representative of Elopement and Fever
Penalty
Summary
Licensed nurses failed to notify a resident’s responsible party (RP) of significant changes in condition and status, including an elopement and a fever. The resident had dementia, bipolar disorder, a cognitive communication deficit, repeated falls, and an active order stating he was not capable of making his own health decisions, with his daughter listed as the RP and emergency contact. He also had an active order for a Wanderguard due to exit-seeking behavior. On 2/28/26, a change of condition note documented that the resident eloped from the facility sometime after he was last seen in bed at 4:00 a.m. and was found by police at a baseball field across from the facility and returned around 5:00 a.m. The note also indicated the Wanderguard was in place but did not alarm when the resident exited. There was no documentation that the RP was notified of this elopement. On 3/1/26, a progress note documented by a licensed nurse indicated a change of condition for fever, with the resident noted to be sneezing and congested, and temperatures of 100.4°F and later 101.1°F recorded, with acetaminophen administered and the MD notified for congestion medicine. There was no documented evidence that the RP was notified of the fever. In an interview, the RP stated she was not informed by the facility of the elopement and learned of it from a friend who heard the resident’s name on a dispatch call, and she later observed new coughing when visiting the resident. The DON stated she expected licensed nurses to complete change of condition reports for elopement and fever and to notify the RP, and confirmed there was no documentation of such notifications. One licensed nurse acknowledged she did not notify the RP of the fever because she did not know it was required. Facility policies on wandering/elopement and change in condition required notification of the resident’s legal representative or resident representative and documentation in the medical record when such events occurred.
Failure to Prevent Elopement of High-Risk Resident Despite Wanderguard Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident at high risk for wandering and elopement, resulting in an actual elopement from the building. The resident had an Elopement and Wandering Risk Observation/assessment score of 12, which placed him at risk for wandering or elopement. His admission record documented diagnoses of dementia, bipolar disorder, cognitive communication deficit, atrial flutter, and a history of repeated falls. A BIMS score of 6 indicated severe cognitive impairment, and physician orders and care plans identified that he was not capable of making his own health decisions, was on anticoagulant therapy, and required safety measures and supervision, including a Wanderguard device and keeping him within supervised view as much as possible. The resident’s care plans included multiple risk areas: falls, elopement and wandering, and bleeding risk due to anticoagulant use. Interventions included identifying patterns of wandering, placing a Wanderguard on his right wrist, checking Wanderguard placement on the left ankle every shift, and providing supervision and reminders to ask for assistance. Orders also directed staff to monitor for signs and symptoms of bleeding every shift and to ensure the Wanderguard was functioning and replaced before expiration, with nursing staff instructed to notify the Activity Director for replacement. Despite these documented risks and interventions, a change of condition note recorded that the resident eloped in the early morning; he was last checked around 4:00 a.m. in bed and was found off premises by police near a baseball field and returned around 5:00 a.m. The note stated the Wanderguard was in place but did not alarm when the resident exited the facility. Interviews and observations further detailed the circumstances and gaps in supervision and monitoring. The resident reported leaving late at night to visit a friend who was a policeman and indicated he walked to a nearby baseball field, which required crossing a neighborhood intersection. The DON stated that nobody noticed the resident had left the facility and acknowledged the elopement care plan had not been updated to reflect the incident. The Activity Director stated she had been on leave and that she or anyone designated to cover her duties was responsible for tracking Wanderguard expiration dates, while the Human Resources Director did not recall being informed that the resident’s Wanderguard had expired. The Maintenance Director reported that door alarms were checked weekly, were loud when activated, and were monitored at two nurse stations, but he was unable to determine how the resident exited through the front door without triggering an alarm. The DON stated there was a potential for the resident to have fallen and sustained injuries when he eloped.
Unattended Unlocked Medication Cart Accessible in Hallway
Penalty
Summary
The deficiency involves failure to ensure that medications were stored securely and accessible only to authorized personnel. During an observation and concurrent interview, surveyors and the Nursing Supervisor (NS) saw medication cart #2 parked in a hallway outside a resident room, unlocked and unattended. The NS immediately went to the cart and locked it, stating that medication carts should always be locked when left unattended and that they needed to be secured so unauthorized people, including residents, could not access the medications. Shortly afterward, a licensed nurse (LN A) exited the nearby resident room and acknowledged responsibility for medication cart #2, admitting that she had left it unlocked and unattended. LN A stated that facility policy required medication carts to be locked when unattended for resident safety, particularly to prevent confused residents from accessing medications. In a separate interview, the Director of Nursing (DON) confirmed that medication carts must always be locked when unattended because only nurses are authorized to access the medications and that leaving a cart unlocked while unattended was a safety issue. Review of the facility’s “Administering Medications” policy indicated that the cart must be visible to the personnel administering medications and all outward sides must be inaccessible to residents or others passing by.
Failure to Follow Lab Orders and Report Abnormal Kidney Function Results
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of care and physician orders for a resident with a history of chronic kidney disease and a displaced bimalleolar fracture of the right lower leg. The resident was admitted in December 2025, and her MDS showed a BIMS score of 12, indicating moderately impaired cognition. A physician’s order dated 12/10/25 directed that CBC and BMP labs be obtained weekly on Wednesday mornings for four weeks. The December 2025 eMAR showed the CBC and BMP as completed on 12/17/25 and 12/31/25, but the EMR contained no evidence that the 12/17/25 labs were actually collected. The DON confirmed the order and the eMAR entries, but could not provide documentation that the 12/17/25 labs were obtained or that results were communicated to the physician. On 12/31/25 at 7:05 a.m., CBC and BMP labs were collected, and the results were reported to the facility on 1/02/26 at 11:51 a.m. The lab report was flagged and showed abnormal values, including an elevated WBC of 14.2 K/mm3, BUN of 42 mg/dL, creatinine of 1.34 mg/dL, and BUN/CREAT ratio of 31, all marked as high. Despite these abnormal and flagged results, the EMR contained no evidence that an SBAR was initiated on 1/02/26 or that the physician was contacted regarding these lab findings. The DON confirmed that these abnormal values should have been reported to the physician and included in an SBAR so the physician could implement interventions, and stated that if an elevated BUN is left untreated, it can cause kidney injury. Subsequent documentation showed that on 1/03/26 at 5 p.m., an SBAR was completed for increased edema to the resident’s bilateral lower extremities, and on 1/04/26 at 9 p.m., another SBAR documented decreased urine output, lower abdominal pain or tenderness, difficulty voiding, and a bladder scan showing approximately 1 liter of retained urine. On 1/07/26 at 11:31 a.m., a nurse’s note recorded the resident’s complaint of back pain rated 10/10 and that the resident was in distress, with an MD order for transfer to the ER for further evaluation. In the ED on 1/08/26, the resident’s BUN was 102 mg/dL and creatinine 1.67 mg/dL, and she was diagnosed with back pain, UTI, AKI, and dehydration. Facility policies required prompt physician notification of diagnostic test results, documentation of changes in condition, and that RNs and LPNs obtain ordered lab tests and notify the physician of changes in condition. Interviews with nursing staff and the DON confirmed that abnormal lab values were expected to be reported to the physician and documented, and that SBARs should be completed for out-of-range labs, which did not occur for the abnormal results reported on 1/02/26.
Failure to Administer Physician-Ordered Pain Medication for Severe Pain
Penalty
Summary
Licensed nursing staff failed to administer physician-ordered pain medication to a resident who was admitted following digestive system surgery and was experiencing moderate to severe pain. The resident's care plan specified that pain should be relieved to a tolerable level, with interventions including administering treatment as ordered, assessing pain every shift, and notifying the physician if pain became unmanageable. Despite these directives, the resident was only given acetaminophen, which was ordered for mild pain, even as her pain levels increased to moderate and severe levels as documented in the medication administration record (MAR). The physician had ordered morphine sulfate for moderate to severe pain, but the resident did not receive any doses of this medication during the period when her pain was documented as worsening. Progress notes indicated that acetaminophen provided minimal relief and that the resident reported nausea from acetaminophen. The MAR and interviews confirmed that the morphine order was not carried out, and there was no documentation that the physician was notified about the resident's escalating pain or the ineffectiveness of the prescribed pain management. The facility pharmacist confirmed that a clarification request was sent to the physician due to a listed morphine allergy, but there was no follow-up from facility staff or the physician, and no documentation of any adverse effects when morphine was eventually administered after the resident's return from hospitalization. Interviews with the resident revealed that she repeatedly requested additional pain medication and felt her pain was not believed or addressed by nursing staff. The DON confirmed that pain assessments and appropriate medication administration were not consistently documented or performed according to the care plan and facility policy. The facility's policies required timely administration of medications as ordered and immediate contact with the prescriber if pain was not controlled, but these procedures were not followed, resulting in the resident experiencing ongoing, severe pain.
Failure to Follow Professional Standards for Insulin Administration
Penalty
Summary
The facility failed to ensure that professional standards of practice were followed for a resident with diabetes mellitus, muscle weakness, and dysphagia. The resident was admitted with orders for both long-acting and short-acting insulin, but there was no documented order for a sliding scale or blood sugar parameters for insulin administration. Additionally, there was no evidence that blood sugar levels were checked prior to administering insulin lispro in the afternoon, as required by standard practice and facility policy. On one occasion, the resident experienced an episode of distress, with vital signs indicating low blood pressure and heart rate, and an oxygen saturation below normal. Paramedics found the resident's blood sugar to be 69 mg/dl, and the resident was subsequently sent to the hospital. The emergency department determined that the resident had experienced a hypoglycemic and mildly hypotensive episode, and recommended reducing insulin doses. Interviews with nursing staff confirmed that blood sugar checks were not performed prior to insulin administration, and that sliding scale and parameter orders were not in place as expected. Further review of facility policies indicated that nurses were required to check blood glucose per physician order or facility protocol and to notify providers of any discrepancies prior to administering insulin. The lack of sliding scale orders, blood sugar parameters, and failure to check blood sugar prior to insulin administration were confirmed by staff and the Director of Nursing. These omissions were not addressed until after the resident's hospitalization.
Disruptive Resident Behavior Affects Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment with comfortable sound levels for Resident 1, who was recovering from a stroke and required uninterrupted sleep for recovery. Resident 4, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, frequently yelled vulgar, offensive, and derogatory language, disrupting Resident 1's sleep. Despite Resident 1's notifications to the charge nurses and the Director of Nursing (DON), the situation persisted, affecting Resident 1's ability to rest and recover. Interviews with various staff members, including the DON, confirmed that Resident 4 exhibited aggressive behavior, which included yelling and physically attacking staff. The DON acknowledged that police intervention was required due to Resident 4's aggression, and Resident 4 was temporarily transferred to a hospital. However, upon return to the facility, Resident 4 continued to exhibit disruptive behavior, impacting the environment for other residents, including Resident 1. Other residents and staff also reported being affected by Resident 4's behavior. Resident 2 and Resident 3 expressed concerns about the noise and aggression, with Resident 3 suggesting that Resident 4's needs might be better met at a mental health facility. Staff members confirmed the ongoing issue with Resident 4's loud and offensive language, indicating that the facility might not be suitable for addressing Resident 4's care needs. The facility's policy on providing a homelike environment with comfortable sound levels was not upheld in this situation.
Delayed Reporting of Influenza Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not reporting an influenza outbreak to the local public health department (LPHD) for nearly three weeks. The outbreak began on January 29, 2025, when two residents tested positive for influenza, and by January 31, 2025, seven more residents had tested positive. In total, 28 residents and staff members were affected. The Infection Preventionist (IP) was away from work during the outbreak's onset and did not notify the LPHD until February 18, 2025. The Director of Nursing (DON) and the Director of Staff Development (DSD) both assumed that the Administrator (ADM) was responsible for reporting the outbreak, leading to a lack of communication and delayed reporting. The facility's policy and procedure, reviewed with the ADM, indicated that a single case of influenza should be reported to the health department. The ADM acknowledged that the IP was responsible for reporting but failed to ensure the LPHD was notified in the IP's absence. The LPHD's Infectious Disease Nurse emphasized the importance of timely notification to provide necessary support and resources to control the outbreak. The delay in reporting prevented the LPHD from offering education, guidance, and support to minimize the spread of the outbreak, as required by Title 17 of the California Code of Regulations.
Failure to Recognize Cardiorespiratory Arrest and Delay in CPR
Penalty
Summary
The facility staff failed to recognize a cardiorespiratory arrest in a resident who was a full-code, leading to a delay in performing CPR. The resident was found unresponsive, apneic, and pulseless by Complainant 5, who arrived at the facility five to seven minutes after being notified of the resident's condition. Despite the presence of an AED at the bedside, it was not used, and CPR was not initiated by the facility staff, resulting in the resident's death. The resident had a history of acute and chronic respiratory failure and was admitted to the facility with these diagnoses. On the day of the incident, the resident was found with low oxygen saturation levels and was initially placed on a nasal cannula, which was later changed to a non-rebreather mask. Despite these interventions, the resident's condition did not improve, and the oxygen saturation remained low. The staff called 911, but CPR was not started until the paramedics arrived. Interviews with the facility staff revealed a lack of recognition of the signs of cardiac arrest and confusion about when to initiate CPR. Licensed Staff A and B were present at the bedside but did not start CPR, as they believed the resident had not lost a pulse. The Director of Nursing stated that CPR should be performed when someone is unresponsive, not breathing, or has lost their pulse, but this protocol was not followed by the staff in this case.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident intentionally struck him in the head and held him down on the floor. Resident 1, who has severe cognitive impairment due to epilepsy, wandered into Resident 2's room and was perceived as a threat by Resident 2, who has moderate cognitive impairment from metabolic encephalopathy. Resident 2 reported that Resident 1 used profanity and attempted to swing at him, prompting Resident 2 to head-butt Resident 1 and force him to the ground. The incident was witnessed by Resident 3, who shared the room with Resident 2, and confirmed that Resident 1 was looking through their belongings and refused to leave when asked. The Director of Nursing and the Business Office Assistant also provided accounts of the altercation, with the latter finding Resident 2 holding Resident 1 in a headlock on the floor. Resident 1 sustained a small cut on his forehead as a result of the incident. The facility's policy on abuse prevention states that residents have the right to be free from physical abuse, which was not upheld in this situation.
Failure to Notify Physician of Missed Medications for Dialysis Resident
Penalty
Summary
The facility failed to notify the physician when a resident consistently missed scheduled medications due to being out at dialysis. The resident, who had a medical history of end-stage renal disease and was dependent on renal dialysis, was admitted to the facility in October 2021. The resident's care plan included instructions to administer medications as ordered and collaborate with the physician for optimal medication dosing times. However, the resident's Medication Administration Record (MAR) for October and November 2024 revealed that medications scheduled between 7:00 AM and 10:00 AM were not administered on multiple days when the resident was out for dialysis. Interviews with facility staff, including Registered Nurse (RN) #15 and Licensed Vocational Nurse (LVN) #11, indicated that the physician was not consistently notified when medications were held due to the resident being unavailable for administration. The Medical Director confirmed that there should be communication regarding missed doses of certain medications, such as insulin and midodrine, but had not been notified of the missed doses for this resident. LVN #11 acknowledged coding the MAR to indicate the resident was out at dialysis and stated that attempts to clarify medication times with the physician had not been successful. The Director of Nursing (DON) and the facility Administrator both stated that the physician should be notified if a medication is not administered for any reason. The DON emphasized that medication timing should align with dialysis schedules, and if a medication is not given, it should be administered after dialysis or according to the physician's instructions. Despite these expectations, the facility did not have a specific policy for notifying physicians of changes in resident status, leading to a lack of communication regarding the missed medications.
Medication Errors for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident with end-stage renal disease (ESRD) was free from significant medication errors, particularly on days when the resident was scheduled for dialysis. The resident, who had a medical history of ESRD and was dependent on renal dialysis, did not receive critical medications for low blood pressure, atrial fibrillation, blood clot prevention, and diabetes management on multiple occasions. The facility's policy required staff to be trained in the timing and administration of medications, especially before and after dialysis, but this was not adhered to. The medication administration records (MAR) for the resident showed that medications such as clopidogrel, apixaban, insulin, and midodrine were often not administered as scheduled on dialysis days. The MAR indicated that these medications were either marked as not given because the resident was out for dialysis or were administered outside the prescribed parameters. For instance, midodrine was given when the resident's blood pressure was above the physician's specified threshold, which could potentially exacerbate the resident's condition. Interviews with various staff members, including Licensed Vocational Nurses (LVNs), Registered Nurses (RNs), the Medical Director, and the Nephrologist, revealed a lack of consistent communication and adherence to medication administration protocols. Staff members admitted to either not administering medications when the resident returned from dialysis or incorrectly documenting medication administration. The Medical Director and Nephrologist emphasized the importance of administering certain medications before or after dialysis, depending on the medication, to avoid adverse effects. However, there was a clear disconnect between the facility's practices and the medical guidance provided, leading to significant medication errors.
Inaccurate MDS Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the preadmission screening and resident review (PASARR) process. Resident #10 was admitted with a medical history of schizoaffective disorder and dementia, and their MDS indicated severe cognitive impairment. However, the MDS did not reflect the resident's positive PASARR status for a serious mental illness, despite the resident receiving antipsychotic medication and having active diagnoses of schizophrenia and non-Alzheimer's dementia. Similarly, Resident #7, who had a history of psychosis, major depressive disorder, and anxiety disorder, was also not accurately represented in the MDS. The MDS showed intact cognition and did not indicate a serious mental illness, even though the resident was receiving antipsychotic medication and had a positive PASARR status for a suspected mental illness. Interviews with facility staff revealed that the MDS Coordinator overlooked the PASARR information when completing the assessments for both residents. The Administrator and Director of Nursing acknowledged that the MDS assessments should have accurately reflected the residents' PASARR status. The failure to include this critical information in the MDS assessments highlights a lapse in the facility's adherence to its policy on certifying the accuracy of resident assessments, as revised in November 2022.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to physician orders for supplemental oxygen flow rates for a resident diagnosed with chronic obstructive pulmonary disease (COPD) and heart failure. The resident, who was admitted on 04/24/2023, had a physician's order for continuous supplemental oxygen at 2 liters per minute via nasal cannula. However, during multiple observations on 11/18/2024 and 11/19/2024, the resident's oxygen concentrator was set at 3.5 liters per minute, contrary to the physician's order. The resident, who had intact cognition, confirmed that the oxygen concentrator should be set at 2 liters per minute. Registered Nurse (RN) #8 acknowledged the discrepancy and adjusted the oxygen concentrator back to the prescribed 2 liters per minute, noting that the resident's oxygen should not be set too high due to the COPD diagnosis. The Director of Nursing (DON) and the attending physician both confirmed that the oxygen should be maintained at 2 liters per minute as per the physician's order. There was no documentation to support any titration of the oxygen to 3.5 liters per minute, indicating a failure to follow the established physician orders and facility policy for oxygen administration.
Improper Medication Storage for Resident
Penalty
Summary
The facility failed to ensure that medications were stored appropriately for one resident, leading to a deficiency. The facility's policy on self-administration of medications requires that residents have the right to self-administer medication if deemed clinically appropriate and safe by the interdisciplinary team. Medications authorized for self-administration should be stored securely, either in the resident's room or on a central medication cart, and any unauthorized medications found at the bedside should be returned to the nurse in charge. However, observations revealed that the resident had multiple medications, including a cough medication, diclofenac gel, hydrophilic wound gel, antifungal powder, muscle cream, and an inhaler, stored in their room in a wicker basket and on the over-the-bed table. The resident, who had a history of allergic rhinitis, chronic pain, and chronic obstructive pulmonary disease, was observed with medications not stored according to the facility's policy. The resident's care plan included interventions for managing a chronic fungal skin rash and impaired skin integrity, requiring specific treatments and monitoring. Despite the resident's intact cognition, as indicated by a BIMS score of 14, the medications were not stored securely, and the resident admitted to self-administering nasal spray and occasionally taking Tylenol without informing the staff. Interviews with facility staff, including LVNs and the DON, confirmed that residents need an order to keep medications at the bedside and should be assessed for their capability to self-administer. The DON stated that medications should be stored in the medication cart and provided upon request, and any medications found in the resident's room should be removed unless an order is in place. The deficiency arose from the failure to adhere to these protocols, as the resident's medications were not stored securely, and there was no evidence of an order allowing the resident to keep them at the bedside.
Failure to Provide Ordered Occupational Therapy
Penalty
Summary
The facility failed to provide occupational therapy as ordered by the physician for a resident who was readmitted with a medical history of congestive heart failure, generalized muscle weakness, and a need for assistance with personal care. The resident was supposed to receive occupational therapy three times a week for four weeks, as per the physician's order and the care plan. However, the service log indicated that the resident only received therapy on three occasions over a two-month period, which was significantly less than the prescribed frequency. Interviews with the resident, the occupational therapist, the Director of Rehabilitation, the Director of Nursing, and the Administrator confirmed the deficiency. The occupational therapist acknowledged that the resident was not seen at the required frequency due to staffing challenges, and all staff interviewed stated that the expectation was for therapy to be provided as ordered. The physician also emphasized the importance of following all physician orders, including those for occupational therapy, although it was unclear if the resident's condition declined due to the lack of therapy.
Failure to Provide Timely Foot Care and Communication Leads to Severe Complications
Penalty
Summary
The facility failed to provide appropriate foot care for a resident with a history of Diabetes Mellitus and peripheral vascular disease, leading to severe complications. The nursing staff did not document daily skin assessments as required by the resident's care plan, resulting in the necrotic condition of the resident's toe going unnoticed for approximately one month. This oversight allowed the condition to progress to wet gangrene, which is a life-threatening stage of necrosis. The nursing staff also failed to promptly notify the resident's physician about the black discoloration of the toe, initially reporting only swelling and discoloration without mentioning the black color. This miscommunication delayed the appropriate medical response and intervention, preventing timely diagnostic testing and treatment that could have mitigated the disease progression. The resident's family member had to intervene by contacting the physician's group directly to ensure the resident received the necessary emergency care. Furthermore, the facility delayed the resident's transfer to the hospital after the emergent condition was discovered, resulting in a significant delay in receiving treatment for sepsis. The resident was eventually transported to the hospital by an outside provider group, not the facility, and arrived in a septic state, necessitating the amputation of the affected toe. The lack of timely and accurate documentation and communication by the nursing staff contributed to the resident's deteriorating condition and subsequent complications.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse when Resident 4 threw water on Resident 3, leading to Resident 3 feeling unsafe. Resident 4, who has diagnoses including neurocognitive disorder with Lewy Bodies, bipolar disorder, and PTSD, was admitted to the facility in 2023. Resident 3, admitted in 2024, has anoxic brain damage and unspecified mood disorder. Both residents were assessed as cognitively intact. The incident occurred when Resident 4, disturbed by Resident 3's continuous screaming, entered Resident 3's room and poured water on her. Resident 4 later explained that the screaming triggered his PTSD, and he acted out of frustration. The incident was confirmed by Licensed Nurse 3, who observed Resident 3's gown and belongings were damp and noted that Resident 3 was on fluid restriction and unable to hold a cup. Resident 3 reported feeling unsafe, fearing further harm from Resident 4. The facility's policy on abuse prevention emphasizes protecting residents from abuse by anyone, including other residents, and maintaining a culture of compassion and care, which was not upheld in this situation.
Failure to Provide Prescribed Pain Medications Upon Discharge
Penalty
Summary
The facility failed to ensure that a resident with metastatic breast cancer was discharged with her physician-prescribed controlled opioid medications, which were necessary for managing her moderate to severe pain. The resident was discharged without her controlled pain medications, leading to severe pain, nausea, and vomiting. This resulted in the resident calling emergency services and being taken to a General Acute Care Hospital (GACH) one day after discharge, where she was diagnosed with opiate withdrawal due to not taking her medications for over 24 hours. The resident was admitted to the facility with diagnoses including malignant neoplasm of the left breast and secondary malignant neoplasm of bone. Her discharge orders specified that she should be discharged with a seven-day supply of narcotics, including oxycodone and morphine. However, the facility's documentation was incomplete, and the section for medications on the post-discharge plan of care was left blank. A handwritten note referenced an attached medication list, which was not provided to the surveyor, and the facility failed to provide evidence that the resident was discharged with the prescribed medications. Interviews with staff and the resident revealed that the nurse responsible for the discharge was not prepared and unaware of the scheduled discharge, leading to a rushed process where the resident's pain medications were not provided. The facility's policy on transfer or discharge did not include procedures for non-emergent discharges or mention the provision of medications upon discharge. The Director of Nursing confirmed that discharging staff should document the medications and quantities provided to residents, which was not done in this case.
Failure to Implement Fall Prevention Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a plan of interventions to address the risk of falls for a resident who was identified as a high fall risk. This resident fell from his wheelchair at the nurses' station, resulting in a bruise on his forehead and a trip to the hospital for evaluation. The incident occurred when the resident, who was agitated, removed the wheel brakes of his wheelchair and attempted to move, causing the wheelchair to get stuck on the railing and the resident to fall. The resident's medical record indicated a fall risk assessment score that identified him as a fall risk, yet there was no care plan with interventions to prevent falls. The Licensed Nurse responsible for the resident's admission assessment confirmed that she completed the fall risk assessment but could not explain why a fall prevention care plan was missing. The interdisciplinary team, which reviews admissions and care plans, also failed to identify the omission of a fall prevention plan. Interviews with staff revealed that the resident was agitated on the day of the fall and that interventions for fall prevention were typically communicated through nurse reports to CNAs. However, the facility's policy on managing fall risks was not followed, as it required staff to identify and implement interventions based on the resident's specific risks. The lack of a fall prevention care plan and the failure to implement appropriate interventions contributed to the resident's fall and subsequent injury.
Resident's Dignity and Timely Care Compromised
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as well as provided timely access to care, which negatively impacted the resident's quality of life. Specifically, Resident 2 did not receive his pain medication in a timely manner, leading him to feel helpless and unimportant. During an interview, Resident 2 expressed that he did not feel entirely safe in the facility, citing an instance where he waited for an hour for his pain medication because the nurses were engaged in a shift change. This delay made him feel that the staff prioritized their shift change over the needs of the patients. The medical records review indicated that Resident 2 was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 13, and he was able to understand and communicate effectively. He was also on a scheduled pain medication regimen. During an interview, a Licensed Nurse (LN C) acknowledged the importance of treating residents with respect and dignity, ensuring their privacy, and responding promptly to their calls for assistance. However, the facility's policy on resident rights, which emphasizes treating residents with kindness, respect, and dignity, was not adhered to in this instance, as evidenced by the delay in providing necessary medication to Resident 2.
Medication Administration Delays
Penalty
Summary
The facility failed to administer scheduled medications within the required time frames for three residents, as per the facility's policy on medication administration. The policy stated that medications scheduled more frequently than daily should be administered within one hour before or after the prescribed time, and those scheduled daily, weekly, or monthly should be administered within two hours before or after the prescribed time. However, 12 scheduled medications were administered as late as three hours after their prescribed times for the residents involved. Resident 1 was observed receiving medications significantly later than scheduled. Levetiracetam and Potassium Chloride, both scheduled for 8:00 AM, were administered at 10:15 AM, and Topiramate, scheduled for 9:00 AM, was given at 10:18 AM. Similarly, Resident 2 received Bumetanide and Acetaminophen, both scheduled for 8:00 AM, at 11:00 AM, and Sertraline HCL, scheduled for 8:59 AM, at 11:01 AM. Keflex, scheduled for 9:00 AM, was administered at 10:59 AM. Resident 3's medications, including Aspirin, Finasteride, and Lithium Carbonate, scheduled for 9:00 AM, were administered between 11:15 AM and 11:30 AM. The Director of Nursing acknowledged that all nurses were aware of the time frame for medication administration, which was one hour before and after the scheduled time. Despite this, the facility did not routinely audit medication pass times, which contributed to the late administration of medications. Complaints from residents about late medication administration were noted during Resident Council Meetings, indicating a pattern of delayed medication administration within the facility.
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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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