Vista Real Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Beaumont, California.
- Location
- 1665 East Eighth Street, Beaumont, California 92223
- CMS Provider Number
- 555740
- Inspections on file
- 30
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Vista Real Post Acute during CMS and state inspections, most recent first.
A resident with dementia and documented moderate cognitive impairment was assessed as high risk for wandering/elopement, but the care plan only allowed wandering in safe areas and lacked specific interventions to prevent exit from the grounds. Staff had observed the resident expressing a desire to go home, refusing meals, and looking for ways to leave near exit doors, yet the elopement care plan was not revised. While the resident was outside in the garden, the activity assistant remained in the lobby instead of providing close supervision, and the resident climbed over the fence and left the grounds despite staff attempts at redirection, leading to notification of law enforcement.
Multiple cardboard boxes were found on the ground outside the designated recycling container instead of being properly stored inside. The Dietary Supervisor and Registered Dietitian confirmed that facility policy requires daily inspection and cleanliness of the garbage area, and acknowledged that leaving boxes outside the container could attract pests and cause infection control issues.
The facility did not provide required follow-up information or education about advance directives (ADs) to several residents or their representatives, as evidenced by interviews and record reviews. Despite facility policy mandating inquiry and assistance regarding ADs upon admission and during care conferences, documentation showed that residents with and without decision-making capacity were not consistently offered information or resources about ADs, and this was acknowledged by the Social Service Director.
Three dietary staff members did not follow the manufacturer's instructions for testing Quat sanitizer solution, with each dipping the test strip for longer than the required one to two seconds. All staff involved acknowledged the error during interviews, and the Registered Dietitian confirmed the importance of following the correct procedure to ensure proper sanitation.
An Activities Assistant stood over a resident with dementia while providing assistance with liquid nourishment, rather than sitting at eye level as required by facility policy. The resident, who required total assistance with ADLs and was seated in a Geri chair, did not receive meal assistance in a manner that promoted safety, dignity, and respect, as outlined in the facility's procedures.
A LVN did not disinfect a blood pressure machine between uses on multiple residents and used gloves stored in her scrub pocket before administering medication. The facility's infection preventionist confirmed that both actions were against established protocols, which require disinfection of medical devices after each use and obtaining gloves from wall-mounted boxes to prevent contamination.
A resident with a history of schizophrenia and moderate cognitive impairment repeatedly consumed less than 50% of meals, but staff failed to document or communicate these refusals to nursing, the MD, or the RD. The resident was not offered alternative meals, and no care plan was developed to address ongoing meal refusals or weight loss, contrary to facility policy.
A resident with severe cognitive impairment and muscle atrophy was left unattended by a CNA, resulting in a fall and head injury. The resident, on one-on-one monitoring due to elopement behavior, was left alone when the CNA stepped out to get dinner. The facility's policy required continuous supervision for high-risk residents, which was not followed, leading to the incident.
A resident with severe cognitive impairment was found unresponsive and later pronounced dead by hospice. The LPN notified the facility physician and hospice but delayed informing the resident's representative (RP) for approximately 2.5 hours. The facility's policy required immediate notification of the RP, which was not followed, potentially affecting the family's opportunity to say goodbye.
A resident with dementia was physically assaulted by another resident with schizophrenia after staff failed to keep them apart, despite prior knowledge of tension between them. The assaulted resident sustained a facial laceration, highlighting a deficiency in the facility's abuse prevention measures.
A resident with a history of aggressive behavior, diagnosed with dementia and schizoaffective disorder, was not adequately supervised, resulting in an incident where they hit another resident with a plastic plate cover, causing injury. Despite known risks and previous altercations, the resident was not under one-on-one supervision. Staff expressed concerns about safety, and the facility's care plan and policies were not effectively implemented, leading to this deficiency.
The facility failed to ensure dietary staff followed proper procedures, leading to potential nutritional deficiencies. A cook used a slotted spoon instead of a measuring cup for pureed meatloaf, affecting portion accuracy. Additionally, a diet aide served ice cream instead of diet cookies to a resident on a renal controlled carbohydrate diet, risking fluid overload and electrolyte imbalance.
The facility failed to follow prescribed menus, affecting residents on pureed, Controlled Carbohydrate (CCHO), and Mechanical Soft diets. The cook did not adhere to puree recipes, leading to diluted nutrient concentrations for residents on pureed diets. Additionally, biscuits were served instead of wheat rolls to residents on CCHO diets, and biscuits were inappropriately served to residents on Mechanical Soft diets, potentially impacting their nutritional needs and safety.
The facility failed to maintain sanitary food preparation and storage practices, with issues such as grime buildup on the ice maker, wear and tear on the mixer, and black grime on the milk refrigerator's gasket. Open food items were exposed to air, and wet scoops were improperly stored, posing a risk of contamination. The hood vent and ceiling were also unclean, potentially leading to cross-contamination.
The facility failed to implement proper infection control practices when a resident's clean clothing was placed on a commode, and the Activity Director was observed with long artificial nails while providing direct care. Both actions were against the facility's infection control policies, as confirmed by staff interviews and observations.
The facility did not maintain a clean and comfortable environment, as waste was left outside disposal bins, potentially attracting pests. Additionally, damaged window blinds in resident rooms disrupted sleep and increased room temperature. The Maintenance Supervisor and Facility Administrator were aware of these issues but did not take corrective action.
The facility failed to ensure that copies of Advance Directives were available in the medical records for two residents with severe cognitive impairment. Despite having executed ADs, the documents were not accessible in the records, and there was no evidence that information about formulating ADs was provided to the residents or their representatives. The Social Service Director acknowledged the oversight and the facility's policy requirement for AD information to be prominently displayed in medical records.
A resident was transferred to a hospital from a clinic appointment without the facility notifying the resident's representative or the LTC Ombudsman, as required by policy. Staff interviews confirmed the oversight, and the facility's policy mandates such notifications.
A facility failed to transcribe a physician's recommendation for wound treatment into an actual order for a resident with a skin tear. The recommendation to cleanse with normal saline, pat dry, and apply a triple antibiotic was not recorded in the treatment administration record, leading to a gap in communication and care implementation. Interviews with the IP and DON confirmed the oversight, which was against the facility's policy requiring immediate recording of verbal orders.
A resident was found with long, untrimmed fingernails with black residue, indicating a failure in nail care. The CNA acknowledged that the nails should have been trimmed during daily checks. Both an RN and the IP noted the risk of skin breakdown and infection due to the untrimmed nails. The facility's policy requires daily cleaning and regular trimming, which was not followed.
A resident with COPD was administered oxygen at 4 LPM, exceeding the physician's order of 1 to 3 LPM. An LVN acknowledged the error, and the DON confirmed the requirement to follow physician orders. This oversight could lead to ineffective oxygen therapy and respiratory distress.
A resident in the facility was not provided with necessary dental care services, despite being identified as having no natural teeth or dentures upon admission. The resident expressed embarrassment and a need for dentures, but no referral to dental services was made. Facility staff, including the RN, SSD, and DON, acknowledged that a referral should have been initiated, as per the facility's policy.
A resident with specific dietary orders for thin liquids and a 120 ml fluid restriction was given honey-thick liquids and 240 ml of fluid during lunch. The Dietary Supervisor failed to update the meal tray ticket, leading to the resident receiving incorrect liquid consistency and excess fluid, which could potentially cause fluid overload.
The facility failed to maintain an effective pest control program, as house flies were observed in the kitchen and dining hall. Staff acknowledged the presence of flies, which were seen landing on surfaces and near food. The facility's policy aimed to keep the environment pest-free, but the presence of flies contradicted this commitment.
A facility failed to initiate a trauma-informed care plan for a resident with a history of trauma, despite the resident's disclosure of anxiety triggers and a personal history of abuse. The resident, with a complex medical history, was observed using noise-cancelling headphones to manage anxiety. Interviews revealed that the care plan should have included trauma-informed interventions, but the social history assessment was not updated in a timely manner.
A facility failed to provide trauma-informed care to a resident with a history of abuse and traumatic events. The resident, who uses noise-cancelling headphones to manage anxiety, was not assessed for trauma triggers, and no care plan was implemented. Staff interviews revealed a lack of training and awareness regarding trauma-informed care. The facility's policy on trauma-informed care was not followed, as there were no records of required training.
Failure to Supervise High-Risk Wanderer Resulting in Elopement Over Facility Fence
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective supervision and individualized interventions for a resident assessed as high risk for wandering and elopement. The resident, admitted with dementia and documented moderate cognitive impairment, had an elopement/wandering care plan dated September 6, 2025, that identified risk for elopement/exit seeking/wandering related to agitation and altered cognitive status, and noted the resident voiced a desire to leave. The only intervention listed was to allow wandering in safe areas within the facility, and there were no specific interventions to prevent the resident from exiting the facility grounds. An elopement and wandering risk assessment dated December 19, 2025, scored the resident at 10, indicating risk for wandering or elopement. Staff documentation on an eINTERACT SBAR dated January 15, 2026, recorded that staff saw the resident jump over the fence, that available staff followed and attempted to redirect the resident back inside the facility grounds, and that the resident refused and continued walking along a nearby street. Interviews with staff further described actions and inactions leading to the elopement. CNA 1, who was assigned to the resident at the time, stated she was informed by CNA 2 that the resident had jumped over the fence, and that staff attempted to redirect the resident but the resident refused, after which law enforcement was contacted. CNA 2 reported being familiar with the resident, noting the resident had verbalized wanting to go home with his brother, had refused meals, and had been observed about a week prior to the incident walking near exit doors and appearing to look for ways to leave the facility. The Activity Assistant stated she knew the resident was at risk for elopement and required close supervision, and that residents at risk for elopement required close supervision when outside. She reported that she observed the resident sitting in the garden while she remained in the lobby, then saw the resident climb over the fence, and acknowledged she should have been outside supervising the resident. The Registered Nurse Supervisor stated that although the facility’s practice was to revise the elopement risk assessment and care plan when exit-seeking was observed, the resident’s care plan was not revised to add new interventions such as 1:1 supervision while outside. The facility’s wandering and elopement policy required that residents identified at risk have care plans including strategies and interventions to maintain safety.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse when multiple cardboard boxes were observed on the ground outside of the designated recycling container, rather than being stored appropriately inside the container. During an observation of the garbage and refuse storage area, surveyors found these boxes on the ground near the recycling container. The Dietary Supervisor confirmed during an interview that there should not be any debris or cardboard boxes on the ground around the containers and acknowledged that such practices could attract pests and cause infection control issues. The Registered Dietitian also stated that garbage containers should be kept clean and inspected daily to ensure no garbage or cardboard boxes are left on the ground in the surrounding area, in accordance with facility policy. A review of the facility's policy indicated that garbage and trash cans must be inspected daily to ensure no debris is present on the ground or surrounding area, and that the lids are closed.
Failure to Provide Advance Directive Information and Follow-Up
Penalty
Summary
The facility failed to ensure that seven out of fourteen residents reviewed for Advance Directives (ADs) were provided with follow-up information regarding the formulation of an AD. Multiple residents, including those with the capacity to make decisions and those with fluctuating or no capacity, were either unsure if they had an AD or could not recall being offered information about one. Record reviews for these residents consistently showed either no documentation of an AD or no evidence that information or education about ADs was provided to the resident or their representative. Interviews with the Social Service Director (SSD) revealed that the facility's protocol was to determine the presence of an AD upon admission and to offer resources if one was not present. However, the SSD acknowledged that follow-up with residents or their representatives was not consistently performed, and documentation of such follow-up was lacking. In several cases, the SSD admitted that education and resources regarding ADs were not provided as required, and that quarterly reviews or care conferences did not include documented follow-up on ADs for residents without one. The facility's own policy required that residents be asked about ADs upon admission and that assistance be offered if an AD was not in place, with this information to be prominently displayed in the medical record. Despite this, the survey found that for the seven residents in question, there was no documented evidence that they or their representatives were provided with the necessary information or education about their right to formulate an AD, as required by facility policy and federal regulations.
Dietary Staff Failed to Follow Sanitizer Testing Instructions
Penalty
Summary
Three dietary staff members failed to follow the manufacturer's instructions for testing the Quaternary Ammonium (Quat) sanitizer solution used for sanitizing food contact surfaces and equipment. Observations and interviews revealed that the Dietary Aide dipped the test strip in the solution for 10 seconds, the Cook for eight seconds, and the Dietary Supervisor for five seconds, instead of the required one to two seconds as specified by the manufacturer's instructions. Each staff member acknowledged during interviews that they did not follow the correct procedure and recognized the importance of adhering to the manufacturer's guidelines to ensure proper sanitizer concentration. The Registered Dietitian confirmed that the test strips should be dipped for one to two seconds to ensure proper sanitation, and not following these instructions could compromise disinfection. The review of the USDA Food Code 2022 and related professional references further supported the requirement to use sanitizer solutions according to the manufacturer's directions. The failure to follow these procedures had the potential to create unsafe and unsanitary kitchen conditions.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
A deficiency occurred when an Activities Assistant (AA) assisted a resident with liquid nourishment while standing over the resident, rather than sitting at eye level as required by facility policy. The resident was observed seated in a Geri chair with the head tilted at a 45-degree angle, positioned in the corner of the activities room. The AA was seen standing directly over the resident during the assistance, which did not align with the facility's expectations for promoting safety, dignity, and respect during meal assistance. The resident involved had a diagnosis of dementia without behavioral disturbance and required total assistance with activities of daily living, including meals. The facility's policy and procedure for meal assistance specifically stated that staff should not stand over residents while assisting them with meals, emphasizing the importance of attention to safety, comfort, and dignity. During interviews, the AA acknowledged that he could either sit or stand while assisting, while the DON confirmed that staff are expected to sit at the resident's eye level. This failure to follow policy had the potential to negatively impact the resident's safety, dignity, and respect.
Failure to Follow Infection Control Protocols for Equipment Disinfection and Glove Use
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to clean and disinfect a blood pressure machine before and after use between multiple residents during blood pressure checks. This was observed during a morning medication pass, where the LVN used the same device on three different residents without performing any disinfection. The LVN later acknowledged in an interview that the equipment should have been disinfected between uses. The facility's Infection Preventionist confirmed that the protocol requires disinfection of medical devices after each use, and the facility's policy also specifies cleaning and wiping the sphygmomanometer and cuff with antiseptic. Additionally, the same LVN was observed donning gloves that had been stored in her scrub pocket prior to administering medication to a resident. In an interview, the LVN stated she believed it was acceptable to use gloves stored in her pocket. However, the Infection Preventionist clarified that facility protocol requires staff to obtain gloves from wall-mounted glove boxes and that storing gloves in pockets is not permitted due to contamination risks. The facility's policy on glove use outlines the importance of using gloves to prevent the spread of infection and specifies when gloves should be used.
Failure to Communicate and Address Resident Meal Refusals and Low Intake
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who consistently consumed less than 50% of meals on multiple occasions. Despite repeated low meal intakes documented throughout March, there was no evidence that these occurrences were communicated to nursing staff, the physician, or the registered dietitian. The resident, who was alert and able to make decisions, reported dissatisfaction with the food, lack of alternatives, and ongoing weight loss. Observations confirmed that the resident was not offered alternative meals when refusing food, and staff interviews revealed a lack of timely communication and documentation regarding meal refusals. Record reviews showed that the resident had a history of schizophrenia and a moderately impaired cognitive status, but retained the capacity to understand and make decisions. The resident's intake records indicated multiple instances of eating less than 50% of meals, yet there was no documentation that these patterns were reported or addressed by the care team. The facility's own policy required that variations in eating patterns be documented and reported to nursing, the physician, and the dietitian, but this was not followed in the resident's case. Interviews with the DON and RD confirmed they were not made aware of the resident's inadequate intake or meal refusals until after the surveyor's inquiry. There was also no evidence that a care plan was developed to address the resident's meal refusals or to provide interventions to prevent further weight loss. The lack of communication and documentation regarding the resident's nutritional intake represented a failure to follow facility policy and to meet the resident's dietary needs and preferences.
Failure to Provide Continuous Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure continuous supervision and assistance for a resident who was on one-on-one monitoring due to severe cognitive impairment and elopement behavior. The resident, who had been admitted with diagnoses including muscle wasting and atrophy, was left unattended by a CNA who stepped out to retrieve the resident's dinner from the hallway. During this brief absence, the resident fell asleep in a chair, slid out, and sustained a 3 cm laceration and bump on the left forehead. Interviews with the Director of Nursing, an LVN, and the CNA confirmed that the resident required constant supervision to prevent accidents. The CNA acknowledged leaving the resident unattended, which was against the facility's policy for one-on-one monitoring. The facility's policy emphasized the importance of continuous bedside observation for residents at high risk for falls, which was not adhered to in this instance, leading to the resident's fall and injury.
Delayed Notification of Resident's Death to Representative
Penalty
Summary
The facility failed to notify the resident's representative (RP) of a decline in the resident's health status in a timely manner. Resident 1, who had severe cognitive impairment, was found unresponsive, not breathing, and without a heartbeat by LVN 2. The facility physician and hospice were notified, and the hospice nurse pronounced the resident dead. However, the RP was not informed until approximately 2.5 hours later, after the hospice had arrived and pronounced the time of death. During interviews, LVN 2 and the Director of Nursing (DON) confirmed that the RP should have been notified immediately after the resident was assessed as deceased. The facility's policy required immediate notification of the RP in such situations, but this was not followed. The delay in communication potentially deprived the family of the opportunity to be present and say goodbye before the resident's remains were released to the mortuary.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide an environment free of physical abuse for a resident, identified as Resident 2, who was assaulted by another resident, Resident 3. Resident 2, who has dementia and moderate cognitive impairment, was accused by Resident 3 of taking his belongings. Despite being aware of the initial altercation at 6:15 a.m., where Resident 3 was agitated and punched a wall, staff did not effectively intervene to prevent further interaction between the two residents. Later that morning, at 10:55 a.m., Resident 2 was walking towards the dining room when Resident 3, who has schizophrenia and the capacity to understand and make decisions, was with the Activity Director in the hallway. Resident 3 suddenly punched Resident 2 on the right side of the face, causing a laceration and swelling. The staff, including the Activity Director and nursing staff, were aware of the need to keep the residents apart but failed to redirect Resident 2 away from Resident 3, leading to the physical altercation. Interviews with the Registered Nurse, Activity Director, and Director of Nursing confirmed that the staff were instructed to keep the residents apart to prevent an altercation. However, the staff did not take adequate measures to separate the residents, resulting in Resident 2 being injured. The facility's policy on abuse prevention emphasizes the need to protect residents from physical abuse, including from other residents, but this was not adhered to in this incident.
Inadequate Supervision Leads to Resident Assault
Penalty
Summary
The facility failed to provide effective supervision for a resident with a history of aggressive behavior, resulting in an incident where this resident hit another resident with a plastic plate cover, causing a bruise and swelling. The aggressive resident, diagnosed with dementia and schizoaffective disorder, had a documented history of fluctuating decision-making capacity and previous altercations with staff and other residents. Despite these known risks, the resident was not under one-on-one supervision at the time of the incident. Interviews with staff revealed that the aggressive resident's behavior had been escalating, and staff members expressed concerns about their safety and the safety of other residents. The resident had previously assaulted a CNA with a fork and made verbal threats to staff and residents. The facility's care plan for the resident included increased supervision and safety measures, but these were not adequately implemented, as evidenced by the incident in the dining room. The Director of Nursing and other staff members acknowledged that the supervision provided was insufficient to prevent the incident. The facility's policy on behavioral assessment and intervention emphasized the need for immediate safety strategies to protect residents and staff, but these measures were not effectively executed, leading to the deficiency.
Deficiencies in Dietary Service and Meal Preparation
Penalty
Summary
The facility failed to ensure that dietary staff were able to carry out the functions of food and nutrition services safely and effectively. During a lunch service, a cook used a slotted spoon instead of a measuring cup to portion pureed meatloaf, failing to follow the standardized recipe. This action had the potential to affect the nutritional needs of four residents who received pureed meat, as the portion size was not accurately measured. The Registered Dietitian confirmed that not measuring the meatloaf portion could impact the nutritional values of the prepared pureed meat. Additionally, a diet aide served ice cream instead of diet cookies to a resident with a physician-ordered renal controlled carbohydrate diet. This error was observed during the lunch meal plating service. The resident's meal tray ticket indicated a requirement for diet cookies, but the diet aide did not follow the Cooks spreadsheet, which guides dietary staff on food items and therapeutic diets. The Registered Dietitian noted that serving ice cream could lead to fluid overload and negatively affect the resident's electrolyte levels due to the high levels of phosphorus and potassium in dairy products.
Menu Non-Compliance and Nutritional Deficiencies
Penalty
Summary
The facility failed to ensure that menus were followed and resident nutritional needs were met during meal preparation and service. On July 8, 2024, the cook did not adhere to the puree recipes when preparing pureed diets for residents with physician-ordered pureed diets. The cook used a slotted spoon to scoop meatloaf without measuring, added excessive beef broth, and did not refer to the recipe, resulting in a diluted consistency. Similar deviations occurred with the preparation of pureed biscuits and vegetables, where the cook did not follow the recipes, leading to a diluted concentration of nutrients. This failure affected four residents on pureed diets, potentially compromising their nutritional intake. Additionally, the facility did not follow the menu for residents on Controlled Carbohydrate (CCHO) diets. During the lunch service, the cook served biscuits instead of the prescribed wheat rolls to all residents, including those on CCHO diets. The Registered Dietitian confirmed that the menu required wheat rolls to help control blood sugar levels for diabetic residents. This oversight affected twelve residents with CCHO diet orders, potentially impacting their blood sugar management. Furthermore, the facility served biscuits to residents on Mechanical Soft diets, contrary to the menu guidelines. The cook served biscuits to all residents, including those on Mechanical Soft diets, which are not supposed to include hard crusts like biscuits. This action affected fourteen residents with Mechanical Soft diet orders, potentially causing difficulties in chewing and swallowing. The Registered Dietitian confirmed that biscuits were inappropriate for these residents, as they could pose a risk to those with chewing or swallowing limitations.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices in the kitchen, as observed during a survey. The ice maker was found to have a buildup of grime, which was confirmed by the Dietary Supervisor (DS) and Maintenance Assistant (MA) during an inspection. The Registered Dietitian (RD) later confirmed that the ice maker should be kept clean to prevent contamination. Additionally, the stationary mixer in the kitchen was observed to have wear and tear, with exposed brown grime, making it difficult to clean. The RD stated that the mixer needed to be replaced due to its unsmooth surface. Further observations revealed that the milk refrigerator's gasket had black grime buildup, which the DS admitted was missed during cleaning. The RD emphasized the importance of cleaning the gasket to prevent cross-contamination. Several pieces of kitchen equipment, including storage shelves and the base of a can opener, were found to have brown grime, indicating a lack of proper sanitation. Open food items were also found exposed to the air in the reach-in freezer, which the DS acknowledged should have been sealed to prevent freezer burn and contamination. Additional issues included wet serving scoops and a plastic container being improperly stored with dry items, which could lead to bacterial growth. The hood vent above the stove was covered with grease and dust, and the ceiling above the steam table had black debris, which the DS identified as dust. The RD confirmed that these areas should be kept clean to prevent cross-contamination. These deficiencies in food safety and sanitation practices posed a risk of foodborne illness to the residents receiving food from the kitchen.
Infection Control Deficiencies: Improper Clothing Storage and Artificial Nails
Penalty
Summary
The facility failed to implement proper infection control practices in two observed instances. In the first instance, a resident's clean clothing, including a pair of black shoes and blue pants, was found placed on top of a commode. This was confirmed through observations and interviews with the resident, a CNA, an RN, and the Infection Preventionist (IP), all of whom acknowledged that clothing should be stored in designated clean areas to prevent contamination and potential infection. The Director of Nursing (DON) also emphasized the importance of CNAs conducting rounds to identify and rectify such infection control issues. In the second instance, the Activity Director (AD) was observed with long artificial nails while providing direct care to residents, which is against the facility's policy. The AD admitted to having artificial nails and was unaware of the policy prohibiting them for direct care staff. The IP and DON confirmed that long artificial nails could pose an infection risk, as they may damage residents' skin and lead to infections. The facility's policy clearly states that direct care staff should maintain short, natural fingernails, and artificial nails are prohibited, especially for those caring for severely ill or immunocompromised residents.
Facility Fails to Maintain Cleanliness and Comfort
Penalty
Summary
The facility failed to maintain a safe and clean environment by not containing waste in closed containers and not providing a homelike environment for residents. Observations revealed multiple discarded medical equipment and non-medical materials surrounding the outside disposal bins, which had the potential to attract insects and rodents. The Maintenance Supervisor (MS) acknowledged awareness of the debris for nine months, and both the Facility Administrator (FA) and Infection Preventionist (IP) confirmed that waste should be properly disposed of in designated bins to prevent pest infestation. The facility's policies on waste disposal and pest control were not adhered to, as garbage and trash were allowed to accumulate outside the designated areas. Additionally, the facility failed to maintain window blinds in resident rooms, affecting the comfort of three residents. Damaged blinds in the rooms of Residents 30, 42, and 43 led to issues such as disrupted sleep and increased room temperature due to uncontrolled sunlight. The MS and FA were aware of the damaged blinds and acknowledged the need for replacement or repair. The facility's maintenance policy requires the maintenance department to keep the building in good repair, which was not followed in this instance.
Failure to Ensure Availability of Advance Directives in Medical Records
Penalty
Summary
The facility failed to ensure that copies of Advance Directives (AD) were available in the medical records for two residents, Residents 4 and 5, who were reviewed for Advance Directives. Resident 5, who was admitted to the facility and had severe cognitive impairment with a BIMS score of 4, had executed an AD as indicated by an acknowledgment form. However, there was no documented evidence of the AD being available in the resident's medical record. During an interview, the Social Service Director (SSD) confirmed that Resident 5's AD should have been accessible to staff and physicians but was not. Similarly, Resident 4, who also had severe cognitive impairment with a BIMS score of 3, had an acknowledgment form indicating an executed AD. However, the AD was not available in the medical record, and there was no evidence that the resident or their representative was provided information about formulating an AD. The SSD acknowledged the responsibility to ensure the availability of ADs in the records and admitted that assistance with the AD should have been offered during a quarterly review with the resident's representative. The facility's policy requires that information about an AD be prominently displayed in the medical record, which was not adhered to in these cases.
Failure to Notify Resident Representative and Ombudsman of Transfer
Penalty
Summary
The facility failed to notify the resident representative and the Office of the State Long-Term Care Ombudsman about the transfer of a resident, identified as Resident 57, to a hospital. This deficiency was identified during a review of closed records, where it was found that there was no documented evidence of a transfer/discharge notice being sent to the resident's representative or the LTC Ombudsman. Resident 57 had been admitted to the facility with a diagnosis that included anxiety disorder. The transfer occurred when the resident was sent to a hospital from a scheduled clinic appointment, and the facility did not follow the required notification procedures. Interviews with facility staff, including the Director of Medical Records, the Director of Nursing, and a Licensed Vocational Nurse, confirmed that the notification process was not followed. The Director of Medical Records acknowledged that a letter should have been sent to both the resident's representative and the LTC Ombudsman. The Director of Nursing and the Licensed Vocational Nurse also confirmed that no notification letter was sent, despite the facility's policy requiring such notifications. The facility's policy, dated October 2022, mandates that transfer or discharge notifications be provided to the resident and their representative, as well as to the LTC Ombudsman, as soon as practicable.
Failure to Transcribe Physician's Wound Treatment Recommendation
Penalty
Summary
The facility failed to ensure that a physician's recommendation for wound treatment was transcribed into an actual physician order for a resident. This oversight was identified during a review of the resident's records, which revealed that the physician's recommendation to cleanse a skin tear with normal saline, pat dry, and apply a triple antibiotic was not transcribed into the resident's physician orders for June and July 2024. The resident, who was admitted with diagnoses including wheelchair dependency and severe debility, had a documented skin tear on the right hand, but the recommended treatment was not recorded in the treatment administration record. Interviews with the Infection Preventionist and the Director of Nursing confirmed that the physician's recommendation was not transcribed into an order and, consequently, was not followed. The facility's policy requires that verbal orders be recorded immediately in the resident's chart, including the prescriber's last name, credentials, date, and time of the order. The failure to transcribe and implement the physician's recommendation resulted in a gap in communication and affected the implementation of the recommended care.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for one of the residents, identified as Resident 42. During an observation and interview, Resident 42 was found to have long, untrimmed fingernails with black residue underneath. The resident expressed that their nails were dirty and needed trimming. A Certified Nurse Assistant (CNA) confirmed the condition of the resident's nails and acknowledged that they should have been trimmed during daily body checks. A Registered Nurse (RN) and the Infection Preventionist (IP) also noted the long, untrimmed nails and highlighted the risk of skin breakdown and infection if the resident were to scratch themselves. The facility's policy on nail care, dated February 2018, mandates daily cleaning and regular trimming to prevent accidental scratching and injury, which was not adhered to in this case.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to adhere to the physician's order for oxygen administration for a resident diagnosed with chronic obstructive pulmonary disease (COPD). The resident, who was admitted with COPD, had a physician's order to receive oxygen therapy via nasal cannula at a rate of 1 to 3 liters per minute (LPM) to maintain oxygen saturation levels at or above 90%. However, during an observation, it was noted that the resident was receiving oxygen at a rate of 4 LPM, which exceeded the prescribed limit. Licensed Vocational Nurse (LVN) 3 acknowledged the discrepancy, stating that the resident should not have been administered oxygen above 3 LPM due to the risk of the resident being unable to breathe independently. The Director of Nursing (DON) confirmed that nursing staff are required to follow physician orders for oxygen therapy, and the facility's policy on oxygen administration mandates verifying and adhering to physician orders. This oversight had the potential to result in ineffective oxygen therapy and respiratory distress for the resident.
Failure to Provide Dental Care Services
Penalty
Summary
The facility failed to provide necessary dental care services for a resident, identified as Resident 55, who was observed to have missing upper and lower teeth. During an interview, Resident 55 expressed the need for dentures and reported not having seen a dentist since admission to the facility. The resident also mentioned feeling embarrassed and unable to smile due to the lack of teeth, and stated that a licensed nurse had been informed of these dental issues but no assistance was provided. Upon review of Resident 55's records, it was noted that the resident was admitted with a diagnosis of anxiety and was identified as having no natural teeth or dentures. A physician's order for a dental consult was dated June 23, 2024, but no referral was made. Interviews with the Registered Nurse, Social Service Director, and Director of Nursing confirmed that the resident should have been referred to dental services upon admission. The facility's policy indicated that social services were responsible for making dental appointments, but this procedure was not followed for Resident 55.
Failure to Follow Physician Diet Orders
Penalty
Summary
The facility failed to adhere to physician orders for a resident during a dining observation. The resident, who had a physician order for thin liquids, was mistakenly given honey-thick apple juice during lunch. This error occurred because the Dietary Supervisor did not update the meal tray ticket to reflect the current physician order, as the resident had previously been on thickened liquids. The Registered Dietitian confirmed that physician orders need to be followed and expressed concern that the resident could be discouraged from drinking due to receiving the incorrect liquid consistency. Additionally, the resident, who was on a 120 ml fluid restriction for lunch due to undergoing dialysis, was served 240 ml of fluid. This occurred because the resident was given ice cream instead of diet cookies, which added an extra 120 ml of fluid to their intake. The Dietary Supervisor acknowledged the mistake, noting that the ice cream was considered a fluid and could potentially lead to fluid overload. The Registered Dietitian confirmed that the resident was only supposed to receive 120 ml of fluid during lunch according to the physician order, and the facility's policy indicated that fluid restrictions are ordered to treat conditions like renal failure.
Pest Control Deficiency in Kitchen and Dining Hall
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen and dining hall, as evidenced by the presence of house flies. On July 8, 2024, during an observation and interview with the Dietary Supervisor, two house flies were seen flying in the kitchen, with one landing near the handwashing station. The Dietary Supervisor acknowledged the presence of flies and mentioned that dietary staff had noticed them a month prior, resorting to shooing them away or using a fly swatter. Later that day, a Dietary Aide observed a house fly landing on a cleaned cutting board surface. Further observations on July 9, 2024, revealed house flies in the dining hall, with one resident swatting a fly away from their food. An Activity Assistant noted that flies enter the dining hall when residents go outside to smoke. A Certified Nurse Assistant confirmed the presence of flies and expressed concern about the potential for cross-contamination and foodborne illnesses. The Registered Dietitian emphasized that no pests should be in the kitchen due to the risk of cross-contamination. The facility's policy on pest control, which was reviewed, indicated a commitment to maintaining a pest-free environment, yet the presence of flies contradicted this policy.
Failure to Initiate Trauma-Informed Care Plan
Penalty
Summary
The facility failed to initiate a comprehensive care plan for a resident with a documented history of trauma, which was identified during a social history assessment. The resident, who has a complex medical history including diabetes, breast cancer with metastasis, bipolar disorder, and anxiety disorder, was observed using noise-cancelling headphones to manage anxiety triggered by loud noises. Despite the resident's disclosure of a personal history of abusive relationships and the presence of trauma, no care plan was developed to address these needs. Interviews with the Director of Nursing and the Social Worker revealed that the resident's care plan should have included trauma-informed care interventions, such as assessing for triggers. However, the Social Worker indicated that the resident's social history assessment would not be updated until the next quarterly assessment. The facility's policy on trauma-informed care requires the interdisciplinary team to care plan for PTSD risks and to identify past trauma, but this was not implemented for the resident in question.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed care to a resident with a history of abusive relationships and exposure to numerous traumatic events. The resident, who uses noise-cancelling headphones to manage anxiety triggered by loud noises, was not assessed for trauma triggers, and no care plan addressing their history of trauma was implemented. Interviews with staff, including a CNA and LVN, revealed a lack of awareness and training on trauma-informed care, with staff not taking any specific actions for residents with a history of abuse. The Social Worker indicated that the responsibility for assessing triggers and implementing a care plan lies with the RN or DON, but this was not done for the resident in question. The resident's Social History Assessment indicated exposure to various traumatic events and a history of substance use disorders, yet the care plans did not address these issues. The facility's policy on trauma-informed care, which includes in-service training and the use of a Significant Life Events Checklist, was not followed, as there were no records of such training from May 2023 to May 2024. The DON acknowledged that the resident had not disclosed a history of abuse until a specific incident occurred, highlighting a gap in the facility's approach to trauma-informed care and the need for proper assessment and care planning for residents with trauma histories.
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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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