Chestnut Ridge Post Acute Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendale, California.
- Location
- 525 South Central Avenue, Glendale, California 91204
- CMS Provider Number
- 056190
- Inspections on file
- 65
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 34 (1 serious)
Citation history
Health deficiencies cited at Chestnut Ridge Post Acute Llc during CMS and state inspections, most recent first.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with type 1 DM experienced a documented hypoglycemic episode after receiving ordered insulin, with blood glucose dropping to 60 mg/dL and then rising to 72 mg/dL after treatment with juice and food. The LVN administered insulin, treated the low blood sugar, and monitored the resident, but did not notify the MD as required by the resident’s orders and facility policies, and there was no documentation of MD notification in the EHR. This failure to follow provider notification orders and hypoglycemia management policy led to the cited deficiency.
A resident with shingles and blisters on the lower back and bilateral buttocks had a physician’s order for daily wound care, but nursing staff failed to assess, monitor, and document the skin condition on admission and weekly thereafter as required by facility policy and practice. The TXN and IP confirmed there was no documentation of ongoing assessment of the blisters, and a covering LVN reported she was not informed she needed to complete weekly skin checks. The DON verified that the admission skin assessment and subsequent weekly skin checks were not completed or documented, despite policies requiring documentation of wound assessments and admission skin assessments.
A resident with a full code status did not receive immediate or effective BLS/CPR when found unresponsive, as staff delayed initiating CPR while searching for code status, failed to use a backboard or Ambu-bag, and performed inconsistent chest compressions. Some staff lacked current BLS/CPR certification, and the emergency cart was not properly stocked, resulting in inadequate life-saving measures.
The facility did not ensure that POLST and advance directive documents were consistently filed and readily accessible in the current medical charts for multiple residents, including those with impaired cognition and serious health conditions. During a medical emergency, staff were unable to locate a resident's POLST, resulting in default initiation of CPR. Staff interviews and record reviews revealed that required documents were often missing, stored in old charts, or not obtained, contrary to facility policy.
Staff failed to immediately initiate CPR and call a code blue when a resident was found unresponsive. Instead, staff delayed action by searching for the resident's code status and did not use the backboard or Ambu-bag during resuscitation. CPR was performed incorrectly, with inadequate compressions and no rescue breaths, and EMS had to move the resident to the floor to continue efforts. These failures resulted in the resident's death and placed all full code residents at risk.
A resident with severe respiratory conditions did not receive prescribed respiratory medications as ordered, with numerous missed and undocumented doses. Staff failed to monitor or assess the resident for respiratory distress after new symptoms and abnormal lab and x-ray results were identified. Critical results were not effectively communicated to the physician, and the care plan was not updated to address the resident's worsening condition. The resident was later found unresponsive and died despite resuscitation efforts.
Licensed nurses did not administer or document multiple scheduled doses of prescribed respiratory medications for a resident with COPD, emphysema, and respiratory failure. The resident, who was oxygen-dependent and required total staff assistance, missed numerous doses of Acetylcysteine, Budesonide, and Ipratropium-Albuterol over several months, despite physician orders and care plan interventions requiring these treatments. The DON and physician confirmed the medications were not given as ordered, in violation of facility policy.
A resident with multiple respiratory conditions and impaired cognition had abnormal lab and chest x-ray results indicating a possible infection. Nursing staff failed to verify that these results were received by the physician or nurse practitioner, and there was no documentation of provider notification or follow-up. As a result, the resident did not receive timely medical intervention for the abnormal findings, and required notification procedures were not followed.
A resident with severe respiratory illnesses, dependent on staff for all care, did not have timely documentation of medication administration by nursing staff. Instead, LPNs entered medication records days or weeks after administration, often only after being alerted by medical records audits. Staff could not recall specific details about medication administration, and documentation was not completed as required by facility policy.
An agitated resident with a history of behavioral disturbances was left unattended in a shared room after a CNA unsuccessfully attempted to intervene, resulting in the resident striking another bedbound resident multiple times with metal wheelchair footrests and causing severe facial injuries. The injured resident required emergency medical care, while another roommate witnessed the attack and expressed fear. Staff were aware of the aggressive resident's history and care plan requirements but failed to implement appropriate interventions or utilize available methods to ensure the safety of all residents present.
A resident with anxiety disorder and moderate cognitive impairment was not assessed or provided with psychosocial support after witnessing and being threatened during a violent incident involving another resident with severe behavioral disturbances. Despite the resident expressing fear and emotional distress, staff did not follow up or notify social services, contrary to facility policy.
A resident did not receive the necessary behavioral health care and services as required. The facility did not provide appropriate behavioral health interventions and supports, as observed and documented by surveyors.
A resident with severe cognitive impairment and a history of wandering was identified as being at risk for elopement, but no care plan was developed to address these behaviors. Staff and DON confirmed the absence of a care plan, despite facility policy requiring interventions and measurable objectives for such risks.
A resident with a history of schizoaffective and psychotic disorders exhibited aggressive behaviors, including choking a CNA and later threatening staff with a knife. After readmission from psychiatric care, the facility did not develop or communicate an individualized behavioral care plan or interventions to staff, despite repeated incidents of aggression and facility policy requirements for comprehensive, person-centered care planning.
Two incidents of abuse occurred when a resident verbally and physically assaulted another resident and later choked a CNA. Both events were witnessed by staff and a family member, but were not reported to the abuse coordinator, ombudsman, police, or state health authorities as required by policy. The affected resident experienced emotional distress, and the lack of timely reporting increased the risk of recurrence and harm.
A resident with dementia and high elopement risk wandered away from an LTC facility due to insufficient staff intervention and training. Despite the resident's care plan requiring frequent monitoring and behavioral intervention, staff failed to act when the resident became agitated and refused to re-enter the facility. The resident was missing for over two hours before being found by law enforcement and placed on a 72-hour hold.
A resident with dementia and high elopement risk managed to leave the facility unsupervised due to inadequate monitoring. The receptionist left his post without coverage, allowing the resident to exit without triggering the wander guard alarm. Facility staff interviews highlighted a failure to adhere to supervision protocols, leading to the resident's elopement and police involvement.
A resident with moderate cognitive impairment requested access to her medical records, but the facility failed to provide the necessary release form, violating her rights. The Administrator instructed the Medical Records Staff to provide the form but did not ensure it was done. The staff claimed the resident later declined the records, which the resident denied, and this was not documented.
The facility failed to ensure the accessibility of the survey binder containing past survey results for residents, as required by policy. During a resident council meeting, residents expressed their unawareness of the survey report's location and the facility's corrective actions. The DON confirmed the binder's importance but could not locate it, as it was taken by MR staff and not returned.
The facility failed to complete quarterly MDS assessments for four residents within the required timeframe, with delays ranging from 27 to 33 days. The MDS Nurse cited a backlog of assessments as the reason for the delays. The DON acknowledged the issue, noting that late assessments could hinder timely updates to care plans. The facility's policy requires MDS completion within 14 days of the ARD, which was not followed.
A facility failed to develop comprehensive care plans for several residents, including one with dementia and others on psychoactive medications, leading to deficiencies in care. A resident with dementia lacked a care plan for their condition, while two residents on psychoactive medications did not have plans to guide safe medication use. Another resident's refusal to store their nasal cannula properly was not addressed in their care plan.
The facility failed to provide proper respiratory care for four residents, including not posting oxygen warning signs for two residents, administering oxygen without a physician's order for one resident, and improper storage and timely replacement of nebulizer equipment for two residents, leading to potential health risks.
The facility failed to maintain proper food storage and sanitation practices, risking foodborne illnesses for residents. Open food items lacked labels and dates, and expired items were found in the kitchen. The Sanitizer Bucket Log, Ice Machine Cleaning Log, and Cleaning and Maintenance Schedule Log had missing entries, indicating inconsistent sanitation practices. The Dietary Service Supervisor admitted to not ensuring logs were completed accurately, contrary to facility policies.
The facility failed to implement its infection control program, leading to deficiencies involving six residents. Issues included unlabeled and improperly stored medical equipment, failure to change feeding syringes, lack of disinfection of reusable equipment, and inadequate hand hygiene practices. These oversights were confirmed through observations and staff interviews, highlighting potential risks of infection spread.
A resident with dementia and psychotic disorder was prescribed Quetiapine and Zolpidem without obtaining informed consent, violating their rights. The facility's policy requires a physician to explain medication effects and alternatives, but documentation was incomplete, lacking the physician's signature.
A resident with communication challenges was not provided with a communication board, despite recommendations from a Speech-Language Pathologist. Staff struggled to understand the resident's needs, leading to frustration and unmet needs. The Director of Nurses acknowledged the availability of communication boards, but staff were unaware of them.
A resident with hemiplegia and dysphagia was not provided necessary assistance during mealtimes, leading to difficulty eating independently. Despite documented needs for supervision and assistance, the resident was left alone, struggling to cut and consume food. A CNA and the DON confirmed the resident required help due to right-side weakness, highlighting a failure to adhere to the facility's ADL support policy.
A resident with severe cognitive impairment and total dependence on staff had their low air loss mattress set incorrectly for a much higher weight than their actual 204 pounds. This error, confirmed by a Treatment Nurse, increased the risk of further skin breakdown and hindered wound healing, as the mattress was too hard. The manufacturer's manual specifies adjusting air pressure based on the patient's weight and comfort, which was not followed.
A facility failed to provide appropriate rehabilitation services and devices for a resident with limited mobility and contractures. The resident was observed with rolled towels between their contracted arms instead of the recommended splints. The facility's physical therapist and rehabilitation director stated that splints should have been used, as rolled towels are not effective. The resident had not been referred for reassessment since 2021, despite the need for appropriate devices to prevent further decline.
The facility failed to maintain a safe environment for two residents. A resident's bed alarm was non-functional, increasing fall risk, while another resident on oxygen therapy had tobacco in their room, posing a fire hazard. Staff acknowledged these oversights, which violated facility policies.
A resident with cognitive impairment was administered medication without proper identity verification. The LVN failed to use multiple identifiers as required by the facility's policy, relying only on the resident's last name. The resident lacked an ID band, and there was no profile picture in the EHR, increasing the risk of medication errors.
Two residents in a LTC facility were found to be on unnecessary psychotropic medications due to inadequate monitoring and documentation. One resident was prescribed Risperidone and Trazodone without specific behavioral indications, and no gradual dose reduction was attempted. Another resident was given Lorazepam without a physician's order after the original order expired. The facility failed to follow its policies on psychoactive drug monitoring and medication administration.
The facility failed to ensure proper storage and labeling of medications. A non-functioning thermometer in the medication room led to unrecorded temperatures, risking medication potency. A resident's medications were improperly labeled with only a room number, not the resident's name, risking medication errors. Additionally, opened multi-dose bottles lacked open dates, crucial for determining expiration. Staff acknowledged these lapses, which violated the facility's policy on medication storage and labeling.
A resident with dysphagia was not provided with the prescribed mechanical soft diet, receiving regular texture food instead, due to an error in the facility's dietary order system. This oversight, lasting from July to October, placed the resident at risk for aspiration and choking. The resident's care plan and physician's orders were not followed, as observed during a dining session where the resident was eating unassisted.
A resident was not screened for the pneumococcal vaccine within the required timeframe upon admission, as per facility policy. The resident, with moderately impaired cognition and requiring assistance with daily activities, was not offered the vaccine until 22 days after admission due to the Infection Preventionist being occupied with other tasks. Both the IP and DON acknowledged the oversight.
A resident's bed siderails were found stained and soiled, with the resident reporting they had been dirty since admission. Despite informing the maintenance supervisor, no cleaning was done. CNA confirmed the siderails were dirty, and housekeeping admitted to not cleaning them, although they are high-touch areas requiring daily cleaning. The facility's policy mandates a clean and comfortable environment.
Two residents with cognitive impairments were involved in an altercation where one poured water on the other, leading to a confrontation. Despite staff awareness, the incident was not reported or investigated, contrary to the facility's abuse policy. The DON and ADM were unaware until informed by surveyors, highlighting a lapse in protocol adherence.
A facility failed to report a resident altercation within the required timeframe. A resident alleged that another resident poured water on him, which was witnessed by an LVN and known by a CNA, but neither reported it promptly. The incident was reported to authorities eight days later. Both residents involved had moderately impaired cognitive skills and required assistance with daily activities. The facility's policy mandates immediate reporting of abuse allegations, which was not followed.
A resident with mental health and hypertension diagnoses went out on pass and did not return as expected. The facility failed to escalate the situation by notifying the MD, DON, or SW, delaying law enforcement notification. The resident returned over 24 hours later, missing medications and appearing disheveled. Staff interviews confirmed the failure to address the resident's absence promptly, highlighting a breach in supervision and safety protocols.
A resident with severe cognitive impairment and a history of wandering was inadequately supervised, leading to an altercation with another resident and a fall. Despite care plans requiring frequent monitoring, documentation showed insufficient supervision. Staff interviews revealed inconsistencies in monitoring practices, and facility policies on wandering were not effectively implemented.
A resident with dementia and behavioral disturbances was inadequately monitored and lacked a specific care plan, leading to an altercation and a fall. Despite known wandering behavior, the facility did not provide necessary supervision or conduct an IDT meeting to address the resident's needs. Observations showed the resident was found on the floor without an alarm, highlighting insufficient safety measures.
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Notify Physician After Resident Hypoglycemic Episode
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a diabetic resident’s hypoglycemic episode despite explicit orders and facility policies requiring such notification. The resident was admitted with diagnoses including type 1 diabetes, duodenal ulcer, and muscle weakness, and was documented as cognitively intact, requiring varying levels of assistance with activities of daily living. Active physician orders and the resident’s diabetes care plan both directed staff to call the provider immediately if the resident’s blood glucose was less than 70 mg/dL and to call as soon as possible when blood glucose values were regularly 70–100 mg/dL for possible regimen adjustment. On the day of the incident, progress notes documented that the resident’s pre-lunch blood glucose was 371 mg/dL and that insulin was administered as ordered. After lunch, the resident’s blood glucose was rechecked and found to be 60 mg/dL. In response, the nurse provided juice and a parfait, and a subsequent blood glucose check showed an increase to 72 mg/dL. The resident was monitored and noted to have no signs of distress. However, there was no documentation in the progress notes that the physician was notified of the hypoglycemic episode, despite the blood glucose level being below 70 mg/dL. During interviews, the LVN who provided care stated that she administered insulin per order, treated the low blood sugar with juice and a parfait, rechecked the blood sugar, and continued to monitor the resident, but forgot to notify the physician of the change in condition. Review of the electronic health record by the DON, QA nurse, and medical records director confirmed there was no documentation that the physician was notified of the hypoglycemic event. Facility policies on Management of Hypoglycemia and Change in a Resident’s Condition or Status required immediate provider notification for blood glucose less than 70 mg/dL and prompt physician notification of changes in a resident’s medical condition, particularly when there were specific instructions to notify the physician of such changes. The failure to notify the physician after the documented hypoglycemic episode constituted the cited deficiency.
Failure to Assess and Document Shingles-Related Skin Condition
Penalty
Summary
The deficiency involves the facility’s failure to assess, monitor, and document a resident’s shingles-related blisters in accordance with its wound care and admission assessment policies and usual practice. The resident was originally admitted with diagnoses including anxiety disorder and hypertension and had moderately impaired cognitive skills, requiring varying levels of assistance with ADLs. A physician’s order directed that the shingles rash on the resident’s bilateral buttocks be cleansed with normal saline, patted dry, and covered with foam dressing daily for 14 days. On admission, a CNA observed red, painful dots on the resident’s lower back area, and the Treatment Nurse (TXN) later confirmed seeing red blisters due to shingles on the lower back when she assessed the resident. The TXN stated that the RN supervisor was responsible for documenting the resident’s skin condition related to the blisters but did not do so, and there was no documentation in the clinical record that the blisters were assessed, documented, and monitored for two weeks starting from the initial assessment date. The TXN also reported that she had been off work for the past two weeks and that the covering nurses did not complete the Weekly Skin Check for the resident during that period. The Infection Preventionist (IP) confirmed awareness that the resident had shingles and blisters upon admission and verified that there was no documentation indicating that the skin condition due to shingles had been assessed, documented, and monitored since admission. A covering LVN reported providing wound care for the resident for the prior two weeks but stated she did not know, and it was not endorsed to her, that she should assess and complete the Weekly Skin Check for the resident. The DON confirmed that the RN supervisor did not assess and document the resident’s shingles blisters on the Skin Check upon admission and that nurses did not assess and document the Weekly Skin Check on the specified subsequent weeks. Review of the facility’s wound care policy showed that nurses are required to record all assessment data obtained when inspecting wounds and any change in the resident’s condition in the medical record, and the admission assessment policy requires nurses to conduct and document physical and skin assessments at admission. The DON stated that, although the wound care policy did not specify follow-up frequency, the facility’s practice was to reassess and document shingles blisters weekly to monitor healing.
Failure to Provide Timely and Effective BLS/CPR to Full Code Resident
Penalty
Summary
Facility staff failed to provide proper and effective Basic Life Support (BLS), including cardiopulmonary resuscitation (CPR), to a resident who was identified as full code when found unresponsive, pulseless, and not breathing. Multiple staff members, including CNAs, RNs, and LVNs, did not immediately call a code blue or initiate CPR upon discovering the resident's condition. Instead, staff delayed action while attempting to verify the resident's code status, and there was confusion and lack of clarity among staff regarding the resident's code status and the location of this information in the medical record. Chest compressions were not started until approximately 12 minutes after the resident was found unresponsive. When CPR was eventually initiated, it was performed on the resident's bed without first placing the resident on a firm, flat surface or using a backboard, which was available in the facility. Staff did not consistently perform continuous and uninterrupted CPR, and there were inconsistencies in the rate and quality of chest compressions. Additionally, staff failed to use the Ambu-bag for rescue breathing, instead placing a non-rebreather mask on the resident, which is not appropriate during CPR. EMS personnel arriving at the scene observed these deficiencies and had to move the resident to the floor to continue CPR. Interviews and record reviews revealed that some staff members lacked current BLS/CPR certification, and there were discrepancies in staff knowledge regarding proper CPR procedures, including compression rates and the use of equipment. Documentation and staff statements indicated that the emergency cart was not properly checked or restocked, resulting in missing essential equipment such as the Ambu-bag. These failures resulted in the resident not receiving timely and effective life-saving measures as required by their full code status.
Removal Plan
- Quality Assurance Nurse (QA) and the RN on duty review the current residents' care profile in the facility's electronic health record (EHR) system, Code Status.
- QA and the RN verify the residents' Code Status via POLST forms and/or physician's orders for Code Status and input the data accordingly in the residents' care profile under Code Status.
- A copy of the list of Full Code residents is made readily available to staff at the nurse's station for reference and is updated by the Social Services Director (SW) 1/designee on every admission/readmission and as needed.
- DON/Designee provides in-service education to nursing staff regarding the availability of the list of residents who are Full Code.
- DON checks the Emergency Cart (EC) and ensures that CPR backboard is available.
- RN and/or Designated Licensed Nurse conduct inventory on the EC utilizing the Emergency Cart Checklist and ensure that CPR backboard is readily available. This is validated by the DON and/or Designee.
- RN and/or Designated Licensed Nurse conduct inventory of the EC utilizing the Emergency Cart Checklist every shift to ensure that all necessary items listed are readily available, including, but not limited to, the CPR backboard.
- DON initiates in-service to RNs, LVNs, and CNAs regarding ensuring a CPR backboard is readily available and used accordingly.
- DON initiates in-service to RNs, LVNs, and CNAs regarding providing rescue breathing, not placement of a non-rebreather mask.
- DON provides continued in-services for all of the facility's RNs, LVNs, and CNAs.
- DON initiates in-service to RNs, LVNs, and CNAs regarding effective and appropriate procedure for CPR, including performing adequate and appropriate chest compressions and rescue breathing, effective and continuous CPR, and ensuring a CPR backboard is readily available and used accordingly.
- Director of Staff Development (DSD) reviews employee files for all current Licensed Nurses and CNAs, specifically to validate that all CPR cards are up to date.
- Identified CNA attends the CPR certification training and is put on temporary suspension until CPR certification is received as part of Direct Care Staff competency.
- Identified LVN that does not have a current CPR/BLS certification is placed on suspension and is not permitted to return to work without an active certification for CPR/BLS.
- Clinical Nurse Consultant provides 1:1 in-service education to the DSD regarding the importance and significance of monitoring and validating direct staff's BLS/CPR competencies and filing of CPR cards.
- DON/Designee provides in-service to CNA 1, CNA 2, LVN 2, and RN 1 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with emphasis on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil and minimal interruptions.
- DON/Designee provides in-service to LVN 2 upon returning to work. LVN 2 is not on the schedule until education/reeducation is provided regarding the facility's policy and procedure titled, Emergency Procedures - Cardiopulmonary Resuscitation.
- DON/Designee provides in-service to LVN 5 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with the emphasis on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil and minimal interruptions.
- A Certified CPR instructor provides mandatory re-education and training for all Licensed Nurses and CNAs which is also attended by the DON and DSD with return demonstration conducted.
- A series of ongoing CPR Certification Training sessions is provided by a Certified CPR instructor until all current Licensed Nurses and CNAs have been provided re-education and training.
- A Code Blue drill is initiated and continues weekly, once per shift for 3 months and monthly thereafter for the purpose of Skills Check Validation through return demonstration of Licensed Nurses and CNAs response to Code Blue situations and providing effective BLS, including CPR.
- An RN is designated as the team leader for Code Blue emergencies.
- Additional CPR training is provided by a Certified CPR Instructor to provide mandatory re-education and training for all Licensed Nurses and CNAs with return demonstration.
- Any Licensed Nurses or CNAs are not permitted to work directly with patients if they do not complete the Certified CPR refresher course.
- Director of Staff Development (DSD)/Designee maintains a log for all Direct Care Staff of their active Certification for BLS/CPR.
- DSD/Designee notifies staff with BLS/CPR certification expiring within a month.
- DSD/Designee presents to the QAA Committee the monthly log for all Direct Care Staff Certification for monitoring and compliance on BLS/CPR certification.
- No Direct Care Staff are permitted to work directly with patients without an active BLS/CPR certification.
- QAA Committee reviews audit findings from the DSD/Designee on BLS/CPR Certification monitoring for further needed corrective actions.
Failure to Maintain Readily Accessible POLST and Advance Directives in Resident Charts
Penalty
Summary
The facility failed to ensure that Provider Orders for Life-Sustaining Treatment (POLST) and advance directives (AD) were consistently and readily retrievable in the current medical charts for 11 out of 100 sampled residents. This deficiency was identified through observation, interviews, and record reviews, which revealed that staff were unable to locate these critical documents during medical emergencies. In one instance, when a resident was found unresponsive and pulseless, nursing staff could not find the resident's POLST or code status in the current chart and, as a result, initiated CPR by default, treating the resident as full code. The Director of Nursing later found the resident's POLST in an old chart, confirming that the document was still valid at the time of the emergency but had not been placed in the current chart as required by facility policy. Further review of additional residents' records showed similar issues, with several POLST and AD documents missing from current medical charts. Interviews with staff, including nurses and the social worker, confirmed that these documents were either not obtained, not printed, or were kept in locations such as email inboxes or old charts rather than being filed in the residents' current medical records. The facility's policy and procedures, as well as the social worker's job description, require that POLST and AD documents be obtained within 48 to 72 hours of admission and be accessible in the medical record to all facility staff. However, staff interviews revealed a lack of consistent adherence to these procedures, with some staff unaware of whether residents had POLST forms or failing to ensure the documents were properly filed. The deficiency affected residents with a range of medical conditions, including chronic obstructive pulmonary disease, chronic kidney disease, dementia, quadriplegia, and other serious health issues. Many of these residents had impaired or severely impaired cognition and lacked the capacity to make decisions, making the presence and accessibility of POLST and AD documents especially critical. The failure to maintain these documents in the current medical charts was acknowledged by both the Director of Nursing and the social worker, who confirmed that the documents should be readily available in the chart and not stored elsewhere.
Failure to Provide Qualified Emergency Response and CPR
Penalty
Summary
Facility staff failed to provide care by qualified persons according to a resident's written plan of care, specifically in the response to a full code resident who was found unresponsive. Multiple staff members, including CNAs, RNs, and LVNs, did not immediately initiate a code blue or begin CPR when the resident was discovered unresponsive. Instead, staff delayed action by first attempting to verify the resident's code status and searching for the POLST form, rather than starting life-saving measures as required by facility policy and professional standards. Interviews and record reviews confirmed that staff were unclear about the correct sequence of actions and did not follow established protocols for emergency response. When CPR was eventually initiated, staff did not place the resident on a firm, flat surface or use the available backboard, as required to ensure effective chest compressions. Instead, CPR was performed on the bed, and the backboard was not utilized. Additionally, staff failed to provide rescue breaths using the Ambu-bag, despite its availability, and instead left the resident on a non-rebreather mask, which is not appropriate during CPR. EMS personnel arriving at the scene observed that CPR was being performed incorrectly, with inconsistent and inadequate chest compressions, and had to move the resident to the floor to continue resuscitation efforts. Documentation and interviews revealed further deficiencies in staff knowledge and execution of CPR, including incorrect compression rates, lack of rescue breaths, and failure to use proper equipment. The facility's own policies, as well as American Heart Association guidelines, were not followed. As a result, the resident was pronounced deceased after prolonged and inadequate resuscitation efforts. The failure to provide qualified and timely emergency care placed all full code residents at risk of not receiving proper life-saving measures during a code blue event.
Failure to Provide and Document Respiratory Care and Timely Physician Notification
Penalty
Summary
The facility failed to provide necessary respiratory care and interventions for a resident with multiple respiratory diagnoses, including COPD, emphysema, respiratory failure with hypoxia, and recurrent pneumonia. The resident was dependent on staff for all care and had significantly impaired cognition. Despite physician orders for scheduled respiratory medications—Acetylcysteine, Budenoside, and Ipratropium-Albuterol—there were numerous missed and undocumented administrations over several months, as evidenced by gaps in the Medication Administration Record (MAR). These medications were specifically ordered to manage the resident's COPD, chest congestion, and shortness of breath, but the resident did not consistently receive them as prescribed. In addition to missed medications, the facility did not adequately monitor or assess the resident for respiratory distress or changes in condition, even after new symptoms and abnormal findings were identified. When a nurse practitioner noted cough, congestion, abnormal lung sounds, and respiratory distress with low oxygen saturation, and when abnormal laboratory and chest x-ray results were received indicating possible infection, there was no documented assessment or monitoring of the resident's respiratory status. The care plan was not revised to address the new or worsening symptoms, and there was no evidence of nursing interventions being initiated in response to these changes. Furthermore, the facility failed to ensure timely and effective communication of critical lab and diagnostic results to the resident's physician. Although results were faxed and texted, there was no confirmation that the physician or nurse practitioner received or reviewed the information. Nurses did not follow up with phone calls or verify receipt, and there was no documentation of provider notification or discussion of the abnormal findings. This lack of communication delayed necessary medical evaluation and treatment. Ultimately, the resident was found unresponsive and pulseless, and despite CPR, was pronounced dead. The facility's policies required prompt assessment, monitoring, and provider notification for changes in condition, but these procedures were not followed.
Failure to Administer Prescribed Respiratory Medications
Penalty
Summary
Licensed nurses failed to administer prescribed respiratory medications to a resident with chronic obstructive pulmonary disease (COPD), emphysema, respiratory failure with hypoxia, recurrent pneumonia, and vascular dementia. The resident was oxygen-dependent and required staff assistance for all activities of daily living. The care plan specifically included interventions to administer medications as ordered for impaired gas exchange and ineffective airway clearance. A review of the Medication Administration Records (MAR) for three months revealed that multiple scheduled doses of three critical respiratory medications—Acetylcysteine Inhalation Solution, Budesonide Inhalation Suspension, and Ipratropium-Albuterol Inhalation Solution—were not documented as administered. Specifically, there were 25 undocumented doses of Acetylcysteine, 31 undocumented doses of Budesonide, and 60 undocumented doses of Ipratropium-Albuterol. Physician progress notes during this period consistently indicated the need to continue regular breathing treatments as scheduled, and nursing notes documented episodes of shortness of breath and diminished lung sounds. During interviews, the Director of Nursing confirmed the absence of documentation for the administration of these medications and acknowledged that the resident did not receive them as ordered. The attending physician also confirmed that missing several doses of these medications, especially consecutively, could trigger a COPD exacerbation. Facility policy required medications to be administered in accordance with prescriber orders, but this was not followed in this case.
Failure to Notify Physician of Abnormal Lab and Diagnostic Results
Penalty
Summary
The facility failed to verify receipt or follow up with the attending physician or nurse practitioner regarding abnormal laboratory and diagnostic results for a resident who exhibited signs of infection. The resident, who had a history of chronic obstructive pulmonary disease, emphysema, respiratory failure with hypoxia, recurrent pneumonia, and aneurysm, was admitted with significant cognitive impairment and was dependent on staff for all care. Orders were placed for a chest x-ray and laboratory tests due to respiratory symptoms, and results showed an elevated white blood cell count and abnormal chest x-ray findings suggestive of an infectious process. Despite these abnormal findings, there was no documented evidence that the physician or nurse practitioner was notified of the results. The results were faxed and texted by the RN to the nurse practitioner and physician, but there was no confirmation of receipt or response. Interviews revealed that the nurse did not verify whether the results were received and did not follow up with the physician. The physician and nurse practitioner both stated they never received the results, and the facility did not have the correct contact information for text communication. The facility's policy required direct communication and documentation of physician notification, especially in cases of significant change in condition, but this was not followed. The lack of communication and verification resulted in the resident not receiving necessary medical intervention for the abnormal findings. The resident subsequently experienced a significant decline, was found unresponsive, and was pronounced deceased. There was no documentation of a change in condition report or assessment related to the abnormal laboratory or diagnostic results, and the required notification procedures were not followed as outlined in the facility's policies.
Failure to Timely Document Medication Administration for Resident with Respiratory Conditions
Penalty
Summary
A deficiency occurred when licensed nursing staff failed to document medication administration for a resident with significant respiratory conditions, including COPD, emphysema, respiratory failure with hypoxia, and recurrent pneumonia. The resident was dependent on staff for all care and required multiple inhaled medications as part of their treatment plan. The Medication Administration Record (MAR) and audit reports revealed that documentation of medication administration was not completed at the time medications were given, but instead was entered days or even weeks later, often only after audits identified missing entries. The audit of the resident's MAR for December showed numerous instances where scheduled medications were administered at times different from those ordered, and documentation was delayed until prompted by the facility's Medical Records Assistant (MRA). Interviews with the involved LVNs confirmed that they could not recall specific details about medication administration for the resident, including which medications were given or the exact times of administration. The LVNs admitted to documenting medication administration retroactively after being notified of missing documentation during audits, rather than at the time of administration as required by facility policy. The facility's policy stated that staff must document medication administration immediately after giving each medication and before administering the next one. The DON confirmed that timely documentation is necessary for accurate monitoring of medication effectiveness and adverse reactions. However, the practice observed was that documentation was completed only after audits identified missing entries, and there was no contemporaneous record of medication administration or reasons for late documentation in the resident's progress notes.
Failure to Protect Residents from Physical Abuse During Behavioral Incident
Penalty
Summary
Facility staff failed to protect two residents from physical abuse when an agitated resident, with a documented history of behavioral disturbances and aggression, was left unattended in a shared room with two other residents. The agitated resident was observed swinging two metal wheelchair footrests in the air, exhibiting aggressive behavior. A certified nurse assistant (CNA) attempted to verbally redirect the resident and remove the footrests but was unsuccessful and left the room to seek assistance, leaving the agitated resident alone with the other two residents, both of whom had significant cognitive and physical impairments. While the CNA was away, the agitated resident struck one of the roommates multiple times in the head with the metal footrests, causing severe facial lacerations, bruising, and pain. The injured resident, who was bedbound and unable to defend herself, required emergency medical attention and was transferred to an acute care hospital for evaluation and treatment of her injuries, which included a forehead hematoma, periorbital laceration, and a possible nasal bone fracture. The other roommate, also bedbound, witnessed the attack and expressed fear for her life. Interviews and record reviews revealed that staff were aware of the aggressive resident's behavioral history, including prior incidents of agitation and aggression, and that care plans specified the need for staff intervention to protect others. However, staff failed to implement appropriate interventions to ensure the safety of the roommates during the incident. The facility's policies on abuse prevention and resident safety did not provide specific guidance for managing an agitated resident in possession of a dangerous object, and staff did not utilize available methods such as overhead paging to request immediate assistance, resulting in a failure to prevent harm.
Failure to Provide Psychosocial Support After Resident-to-Resident Altercation
Penalty
Summary
Facility staff failed to provide medically related social services to support a resident's psychosocial well-being after the resident witnessed and was threatened during a violent incident involving another resident. The incident occurred when a resident with severe cognitive impairment and behavioral disturbances became agitated, removed metal wheelchair footrests, and began swinging them aggressively in a shared room. Staff attempted to intervene but were unable to de-escalate the situation before the agitated resident struck another bedbound roommate, causing visible injuries. During this event, another resident in the room, who was also bedbound and had a diagnosis of anxiety disorder and moderate cognitive impairment, was directly threatened and feared for her safety. Following the incident, the resident who witnessed and was threatened by the aggressive behavior reported experiencing fear, anxiety, and emotional distress. Despite these clear signs of psychosocial trauma, no nursing or facility staff checked on or followed up with this resident after the event. Interviews with staff confirmed that they were unaware of the resident's emotional state and had not assessed her for trauma or distress. The Director of Nursing and the Registered Nurse involved both acknowledged that the resident should have been assessed for psychosocial well-being and that the Social Services Designee should have been notified to provide support. A review of facility policy indicated that staff are responsible for identifying and addressing factors negatively affecting residents' psychosocial functioning, including resident-to-resident altercations and behavioral problems. The policy also states that social services staff are responsible for providing or arranging for mental and psychosocial counseling services as needed. In this case, the facility did not follow its own policy, resulting in a failure to provide necessary social services to a resident who experienced significant emotional distress after a violent incident.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents in need. The lack of appropriate behavioral health care and services was directly observed and documented during the survey.
Failure to Develop Care Plan for Resident at Risk of Wandering and Elopement
Penalty
Summary
A comprehensive, person-centered care plan was not developed for a resident who was assessed to be at risk for wandering and elopement. The resident, admitted with diagnoses including Alzheimer's disease, dementia, and cognitive communication disease, was documented as having severe cognitive impairment and requiring moderate to substantial assistance with mobility and self-care. The resident's Elopement Evaluation indicated a risk for wandering and elopement, and staff interviews confirmed that the resident wandered around the facility and was at risk for elopement. Despite these assessments and observations, a review of the resident's active care plans revealed that no care plan had been initiated to address the behaviors of wandering or risk of elopement. The Director of Nursing acknowledged the absence of such a care plan and stated that interventions should have been included to inform staff of specific actions to take. The facility's policy required care plans to include measurable objectives, timeframes, and interventions addressing the underlying sources of problem areas, but these requirements were not met for this resident.
Failure to Develop and Communicate Individualized Behavioral Care Plan After Resident Aggression
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and sufficient staffing to address and manage the behavioral health care needs of a resident diagnosed with schizoaffective disorder-bipolar type and psychotic disorder. After an incident in which the resident choked a CNA, resulting in a temporary involuntary psychiatric commitment, the resident was readmitted to the facility. Upon readmission, the facility did not thoroughly evaluate the resident's behavioral aggressiveness or develop and communicate individualized, comprehensive care plan interventions to all staff, despite the resident's recent history of violent behavior. Documentation and interviews revealed that the interdisciplinary team (IDT) did not discuss or document the resident's aggressive behavior or history of violence in the care plan or IDT notes. Progress notes following the resident's readmission indicated further episodes of verbal and physical aggression, but no individualized behavioral interventions were developed or implemented to prevent further incidents or protect staff and other residents. Staff assigned to supervise the resident were not provided with specific care plans or instructions on managing the resident's behaviors, only general directions to keep the resident safe and prevent fights. This lack of individualized assessment, care planning, and communication led to another serious incident in which the resident, while unsupervised, obtained a bread knife, threatened staff, and acted violently in the facility lobby. The resident's roommate and other cognitively impaired residents were placed at risk during these events. Facility policies required comprehensive, person-centered care plans and thorough behavioral assessments, but these were not followed, as evidenced by the absence of specific interventions and monitoring for the resident's aggressive behaviors.
Failure to Timely Report Resident-to-Resident and Resident-to-Staff Abuse
Penalty
Summary
The facility failed to immediately report two separate incidents involving abuse and physical altercations between residents and a staff member. On the morning of 5/3/2025, one resident verbally abused another by yelling profanity, then physically pushed the other resident's wheelchair, spun him around, and grabbed his jacket. Multiple staff members and a housekeeper witnessed the incident, and the affected resident reported feeling upset, sad, and discouraged. Despite being reported to the charge nurse and witnessed by several staff, the incident was not reported to the abuse coordinator, ombudsman, police, or the state health department as required by facility policy. Later the same day, the same resident attacked a Certified Nurse Assistant (CNA) by choking her in another resident's room. This incident was witnessed by a family member, who intervened and reported the event to facility leadership. The police were called, and the resident was transferred to a general acute care hospital under a 5150 psychiatric hold. The facility's progress notes documented the physical aggression, but the incident was not reported to the appropriate authorities within the required timeframe. Interviews with staff, including CNAs, LVNs, and the Director of Nursing, confirmed that both incidents met the facility's criteria for abuse and should have been reported immediately, but were not. The facility's policies require all allegations of abuse or mistreatment to be reported promptly, no later than two hours if abuse is involved. The failure to report these incidents resulted in emotional distress for the affected resident and had the potential for recurrence and harm to other residents and staff.
Inadequate Staff Training Leads to Resident Elopement
Penalty
Summary
The facility failed to provide sufficient nursing staff with the necessary knowledge, training, and skills to address the behavioral healthcare needs of a resident diagnosed with dementia and assessed at high risk for elopement. The resident, who had a history of elopement and was known to exhibit wandering behavior, was not adequately monitored or assisted according to their care plan. On the evening of 11/27/2024, the resident became agitated and refused to re-enter the facility after being out on pass with a family member. Despite the resident's care plan indicating the need for frequent monitoring and intervention in cases of behavioral problems, the staff did not take appropriate action to address the situation. The Registered Nurse (RN) on duty failed to implement the resident's care plan, which included interventions such as speaking in a calm manner, diverting attention, and removing the resident from the situation to an alternate location if necessary. Instead, the RN instructed the family member to follow the resident and contact law enforcement, rather than sending facility staff to intervene. As a result, the resident was missing for two and a half hours before being found by local law enforcement and subsequently placed on a 72-hour hold due to being a danger to themselves. Interviews with facility staff revealed a lack of awareness and training regarding the resident's elopement risk and behavioral needs. The Certified Nursing Assistant (CNA) and Licensed Vocational Nurse (LVN) were not fully informed of the resident's high elopement risk, and the Director of Nursing (DON) acknowledged that the facility did not have a competency checklist for dementia care. The facility's policy and procedures indicated that staff should be trained to support residents in distress, but the deficiency in staff training and intervention contributed to the resident's elopement and subsequent hospitalization.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate monitoring and supervision for a resident with severely impaired cognition and memory, who was assessed at high risk for elopement due to dementia. The resident, admitted on 10/23/2024, had a history of elopement attempts and expressed a desire to leave the facility. Despite being equipped with a wander guard, the resident managed to elope from the facility on 11/14/2024, and as of 11/15/2024, had not been found by the facility staff. The incident occurred when the receptionist, responsible for monitoring the lobby area, left his post to use the restroom without ensuring coverage. The receptionist had previously observed the resident sitting in the activity room with a packed plastic bag, indicating a potential attempt to leave. The facility's video footage confirmed that the receptionist was absent from his post when the resident exited the facility without supervision. The wander guard alarm did not activate, and the receptionist was unsure if the resident was wearing the device at the time of elopement. Interviews with facility staff, including the LVN, ADON, and DON, revealed that the receptionist did not follow protocol to find coverage before leaving his post, contributing to the resident's unsupervised departure. The facility's policies emphasized the importance of resident supervision and safety, but these were not adequately implemented, resulting in the resident's elopement and subsequent police involvement to locate the resident.
Failure to Provide Resident Access to Medical Records
Penalty
Summary
The facility failed to provide a resident with access to personal and medical records upon request, violating the resident's rights. Resident 1, who was admitted with a primary diagnosis of polyneuropathies and had moderate cognitive impairment, requested a copy of her medical records in August 2024. Despite having the capacity to understand and make decisions, Resident 1 did not receive the medical release form necessary to obtain her records. The facility's policy required that residents have access to their records within 5 days of a request, but this was not adhered to. Interviews revealed that the Administrator instructed the Medical Records Staff to provide the release form to Resident 1 but did not follow up to ensure it was done. The Medical Records Staff claimed that Resident 1 later expressed disinterest in obtaining her records, a statement that Resident 1 denied. The staff did not document this alleged change of mind. The facility's policy and procedure on resident rights and release of information were not followed, leading to the deficiency in providing the resident access to her medical records.
Inaccessible Survey Binder
Penalty
Summary
The facility failed to ensure that the survey binder containing past survey results was accessible and available to all residents, including those who attended the resident council meeting. This deficiency was identified during interviews, observations, and record reviews. Residents expressed their lack of awareness regarding the availability and location of the survey report and the corrective actions taken by the facility. The Director of Nurses (DON) acknowledged the importance of making the survey binder accessible, but during an observation, the binder could not be located in its designated place. The report highlights that the survey binder was taken by the Medical Record (MR) staff to her office and was not returned, leading to its inaccessibility. The facility's policy and procedure on Resident Rights, which guarantees residents the right to examine survey results, was not adhered to. This oversight had the potential to leave residents and their legal representatives uninformed about the facility's past deficiencies and the measures taken to address them.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that the quarterly Minimum Data Sets (MDS) for four sampled residents were completed within the required time frame. The MDS Nurse acknowledged that the assessments for Residents 2, 30, 60, and 77 were completed late, with delays ranging from 27 to 33 calendar days past the deadline. The MDS Nurse attributed the delays to a backlog of assessments that she was unable to complete on time. The Director of Nurses (DON) was aware of the late assessments and expressed concern that delays could prevent timely updates to care plans if there were changes in the residents' conditions. The facility's policy and procedure, revised in July 2017, mandates that MDS assessments be completed and submitted in accordance with federal and state timeframes, specifically within 14 calendar days following the Assessment Reference Date (ARD). However, this policy was not adhered to, resulting in the identified deficiency.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four of five sampled residents, leading to deficiencies in care. Resident 58, who was diagnosed with dementia, schizophrenia, and anxiety disorder, did not have a care plan addressing their dementia. This oversight was confirmed during a review of the resident's records and interviews with the LVN and DON, who acknowledged the absence of a care plan for dementia, which is crucial for guiding staff in providing appropriate care and interventions. Residents 3 and 70, both receiving psychoactive medications, also lacked care plans to address the use of these medications. Resident 3, diagnosed with schizoaffective disorder and dementia, was receiving Olanzapine without a corresponding care plan to guide staff on monitoring and managing potential side effects. Similarly, Resident 70, who was on multiple psychotropic medications for dementia and psychotic disorder, did not have a care plan detailing interventions for safe medication management. Interviews with nursing staff highlighted the importance of such care plans in ensuring resident safety and effective monitoring of medication effects. Resident 63, diagnosed with COPD and bronchiectasis, refused to place their nasal cannula in a bag when not in use, yet this behavior was not addressed in their care plan. Despite having the mental capacity to make medical decisions, the resident's preference was not documented or planned for, as confirmed by interviews with the DON and observations. The facility's policy requires comprehensive care plans to be developed within a specific timeframe, but this was not adhered to, resulting in potential risks to resident care and safety.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents, leading to several deficiencies. Resident 258 and Resident 63, who were receiving oxygen therapy, did not have oxygen in use warning signs posted on their doorways, which is against the facility's policy. This oversight was confirmed by interviews with staff, who acknowledged the importance of such signage due to the presence of smokers in the facility, which could pose a fire hazard. Resident 258 was also receiving oxygen therapy without a physician's order since admission, which was a significant oversight. The lack of a physician's order for oxygen administration was confirmed during interviews with the nursing staff and the Director of Nursing (DON), who acknowledged that oxygen is a drug and should have a physician's order prior to administration to prevent potential oxygen toxicity. Additionally, the facility failed to store and change nebulizer equipment for Residents 26 and 55 according to policy. Resident 26's nebulizer mask was found stored unsanitarily in a drawer without a protective bag, posing a risk for respiratory infection. Similarly, Resident 55's nebulizer mask was not changed every seven days as required, which was confirmed by the Infection Preventionist and the DON, indicating a risk for infection due to prolonged use of the same equipment.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage, preparation, and distribution practices, which placed residents at risk for foodborne illnesses. During an inspection, several open food items were found without labels or open dates, including a liquid whole egg carton, apple sauce, cottage cheese, sliced watermelon, buttermilk ranch dressing, and sliced potatoes. The facility's policy requires that newly opened food items be labeled with an open date and a use-by date, which was not adhered to. Additionally, expired food items such as Parmesan cheese, turkey salad, nutmeg, and turmeric were found in the kitchen, contrary to the facility's policy that no food should be kept beyond its expiration date. The facility also failed to maintain proper sanitation practices. The Sanitizer Bucket Log, which is supposed to be filled out after each meal and use, had missing entries for several dates, indicating that the kitchen was not sanitized according to the facility's policy. The Dietary Service Supervisor (DSS) acknowledged the missing entries and stated that it was the responsibility of the kitchen staff to complete the log. Furthermore, the Ice Machine Cleaning Log and the Cleaning and Maintenance Schedule Log had multiple missing entries, indicating a lack of consistent monitoring and documentation of cleaning practices. The DSS admitted to not following up with the staff to ensure that logs were filled out accurately and consistently. The facility's policy requires the Food and Nutrition Services Director to write a cleaning schedule designating tasks by job title or employee, which was not effectively implemented. These deficiencies in food storage, expiration monitoring, and sanitation practices highlight a significant lapse in maintaining sanitary conditions in the facility's kitchen, potentially exposing residents to health risks.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement its infection control program for six sampled residents, leading to several deficiencies. For Resident 258, the nasal cannula, handheld nebulizer circuit, and oxygen humidifier were not labeled with the date of initial use, and the nebulizer circuit was not stored in a plastic bag. This oversight was confirmed by interviews with the LVN, RN, and Infection Preventionist Nurse, who acknowledged that the lack of labeling and proper storage could lead to the equipment harboring bacteria and viruses, potentially spreading infections. Resident 86's feeding syringe was not changed every 24 hours as required, which was confirmed during an observation and interview with the Director of Staff Development. The syringe, used for flushing the G-tube and administering medications, was found to be unchanged for two days, increasing the risk of infection. The Director of Nursing confirmed that the facility's policy required the syringe to be changed daily to prevent infection. For Resident 55, the blood pressure monitor was not cleaned and disinfected before and after use, as observed during a nurse's routine check. This practice was against the facility's policy, which mandates disinfection of reusable equipment between uses to prevent infection spread. Additionally, staff failed to perform hand hygiene while distributing meal trays to Residents 43 and 257, as observed during meal service. The CNA admitted to not washing hands between assisting the two residents, which was against the facility's hand hygiene policy designed to prevent cross-contamination.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications prescribed to a resident, identified as Resident 99, who was receiving Quetiapine and Zolpidem. The resident was admitted with diagnoses including dementia, psychotic disorder, and cognitive communication deficit, and was noted to have severely impaired cognitive status. Observations and interviews revealed that the resident was confused and agitated, and staff redirected the resident's attention as needed. However, the facility did not have a documented informed consent for the psychotropic medications, which is required by their policy. Interviews with the Director of Staff Development and the Director of Nurses confirmed that the informed consent for the psychotropic drugs was not obtained as per policy, which requires a physician to explain the medications' effects and alternatives to the resident or their responsible party. The facility's policy mandates that informed consent should be documented with the physician's signature, which was missing in this case. This oversight violated the resident's rights to be informed and involved in their care decisions, as outlined in the facility's policies on informed consent and resident rights.
Failure to Provide Communication Board for Resident
Penalty
Summary
The facility failed to provide a communication board for a resident with significant communication challenges, resulting in the resident's needs not being effectively communicated or met. The resident, who had been admitted with conditions including hemiplegia, hemiparesis, aphasia, and cognitive communication deficits, was recommended by a Speech-Language Pathologist to use a communication board to facilitate communication. Despite this recommendation, the resident was observed struggling to communicate her needs during meal times, as staff members were unable to understand her gestures and nonverbal cues. Multiple staff members, including CNAs, were observed attempting to guess the resident's needs without the aid of a communication board, leading to prolonged periods of misunderstanding and frustration for the resident. Interviews with staff revealed that they were unaware of the existence of communication boards in the facility, despite the Director of Nurses stating that such tools were available. The facility's policy on accommodating individual needs emphasized the importance of promoting communication and maintaining dignity, which was not upheld in this case.
Failure to Assist Resident During Mealtimes
Penalty
Summary
The facility failed to provide necessary assistance to a resident during mealtimes, which led to the resident's inability to eat independently. The resident, who was admitted with conditions including hemiplegia, hemiparesis, and dysphagia, required supervision and assistance with eating due to right-side weakness. Despite these needs being documented in the resident's care plan and nutritional screening, the resident was observed eating alone without assistance, struggling to cut and consume a piece of chicken. The resident's inability to reach the fork and use her right arm was evident, and no staff was present to assist her during the meal. The deficiency was further highlighted when a CNA confirmed that the resident should have been assisted during mealtimes, as the chicken was too large for her to manage independently. The CNA acknowledged the resident's right-side weakness and the necessity for assistance in cutting the food into manageable pieces. The Director of Nurses also confirmed that the resident should have received assistance during meals to prevent potential risks such as malnutrition and weight loss. The facility's policy on supporting activities of daily living, including dining assistance, was not adhered to in this instance.
Incorrect LAL Mattress Settings for Resident
Penalty
Summary
The facility failed to provide necessary care and services for a resident with skin breakdown and pressure injuries by not ensuring the correct settings on a low air loss mattress (LAL Mattress). The resident, who was admitted with diagnoses including COPD, muscle weakness, and generalized osteoarthritis, was totally dependent on staff for daily activities and had severe cognitive impairment. Despite the resident's weight being recorded as 204 pounds, the LAL Mattress was incorrectly set for a person weighing 550 pounds, which was observed during a facility visit. The Treatment Nurse confirmed that the mattress settings were incorrect and should have been set at 250 pounds based on the resident's actual weight. The incorrect settings made the mattress too hard, potentially preventing wound healing and increasing the risk of further skin breakdown. The manufacturer's manual for the mattress indicated that the air pressure should be adjusted based on the patient's weight and comfort levels, which was not adhered to in this case.
Failure to Provide Appropriate Rehabilitation Services and Devices
Penalty
Summary
The facility failed to provide appropriate rehabilitation services and devices to maintain or improve mobility for a resident with limited mobility and contractures in both arms. The resident, who was admitted with diagnoses including dementia, schizophrenia, and anxiety disorder, was observed with rolled towels placed between their contracted arms instead of the recommended splints. The resident's care plan indicated limitations in shoulders, elbows, and fingers, with interventions to prevent further contractures using pillows or splints. However, the use of rolled towels was not effective or recommended by the facility's physical therapist and rehabilitation director. The physical therapist and rehabilitation director both stated that splints should have been used to prevent further contractures, as rolled towels are not a standard practice and are not therapeutic. The resident had not been referred to rehabilitation for reassessment since 2021, despite the need for appropriate devices to prevent further decline. The Director of Nurses confirmed that towels were inadequate for preventing contractures and acknowledged the need for reevaluation. The facility's policy indicated that residents with limited ROM should receive appropriate treatment and services to prevent further decrease, which was not adhered to in this case.
Failure to Maintain Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe and hazard-free environment for two residents, leading to potential risks. For Resident 87, the bed alarm, which was intended to monitor the resident's movements and prevent falls, was found to be non-functional. The bed pad sensor was not connected to the bed alarm monitor, and the monitor's light was off, indicating it was not operational. Certified Nursing Assistants (CNAs) acknowledged the malfunction and admitted to not checking the alarm due to being occupied with other duties. This oversight placed Resident 87, who has dementia and muscle weakness, at risk of falls when attempting to get out of bed without assistance. Resident 63, who is a smoker and receives oxygen therapy, was found to have a bag of tobacco at the bedside, which is against the facility's policy. The resident, diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and bronchiectasis, was observed with tobacco and a pipe in his room, despite being on oxygen therapy. The Social Worker Designee and Registered Nurse Supervisor confirmed the presence of tobacco and acknowledged that it was not safe for the resident to have smoking materials in the room due to the risk of fire. The facility's policies clearly state that residents on oxygen therapy should not have smoking materials in their possession or in their rooms. The Director of Nursing reiterated that smoking materials should be managed by the activities staff and not kept with residents, especially those on oxygen therapy. The failure to adhere to these policies posed a significant safety risk to Resident 63 and others in the facility.
Failure to Verify Resident Identity Before Medication Administration
Penalty
Summary
The facility failed to verify the identity of a resident before administering medication, which was not in accordance with the facility's policy and procedure. The incident involved a resident who was admitted with diagnoses including diabetes mellitus and hypertension. The resident had moderately impaired cognitive skills and required varying levels of assistance with daily activities. On the day of the incident, the resident was administered a multivitamin-mineral tablet without proper identity verification. The Licensed Vocational Nurse (LVN) responsible for administering the medication did not use the required identifiers to confirm the resident's identity. The resident did not have an identification band, and there was no profile picture available in the electronic health record (EHR). The LVN only called the resident's last name, which was insufficient according to the facility's policy. The Director of Nursing confirmed that the facility's policy required multiple identifiers, such as an ID band, photograph, and verification with other personnel, to prevent medication errors.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications, as required by their policy and procedure. Resident 58, diagnosed with schizophrenia and depression, was prescribed Risperidone and Trazodone without adequate monitoring or documentation of the behaviors that warranted their use. Despite being nonverbal and bedbound, the resident was noted to have no specific episodes of behavior that justified the continued use of these medications. The facility's staff did not properly track or document the resident's behaviors, which prevented the assessment needed to initiate a gradual dose reduction (GDR). The Director of Nurses (DON) acknowledged that the indications for the medications were not specific enough and that the facility's consultant pharmacist's recommendations for GDR were not adequately reviewed or acted upon. Resident 4 was administered Lorazepam without a physician's order, which is a violation of the facility's medication administration policy. The resident, who had severe cognitive impairment, was given Lorazepam on multiple occasions after the original order had expired. The nursing staff failed to obtain a new order before administering the medication, and there was no documentation in the Medication Administration Record (MAR) to support the administration of Lorazepam. The DON confirmed that the medication should not have been given without a valid order and that the resident should have been reassessed for the need for Lorazepam. The facility's policies on psychoactive drug monitoring and antipsychotic medication use were not followed, leading to the inappropriate use of psychotropic medications for both residents. The lack of specific documentation and monitoring of behaviors, as well as the failure to reassess the need for continued medication use, contributed to the deficiencies identified by the surveyors. The facility's failure to adhere to its own policies and federal regulations put the residents at risk for unnecessary medication use.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, as observed during a survey. In the medication room, the thermometer was not functioning, and the temperature was not recorded in the Daily Room Temperature Log, which is essential to maintain the potency of medications. The Licensed Vocational Nurse (LVN) and the Director of Staff Development (DSD) confirmed that the temperature was not documented, and the thermometer was not working, indicating a lapse in monitoring the medication storage conditions. Additionally, the facility did not label multi-dose medication bottles with the resident's name, as required. For Resident 257, who was admitted with hypertension and muscle weakness, opened bottles of Ascorbic acid, Vitamin E, and Vitamin D3 were found in the medication cart labeled only with the room number. The LVN acknowledged that the resident's name should have been on the bottles to prevent medication errors, especially if the resident was moved to a different room. Furthermore, the facility failed to label opened multi-dose bottles with the open date, which is crucial for determining the expiration of liquid medications. LVN 7 observed that bottles of Pro-Stat, bismuth subsalicylate, Geri-Lanta, and sterile normal saline were not labeled with the open date. The Infection Preventionist (IP) and the Director of Nursing (DON) emphasized the importance of labeling to ensure medication potency and prevent infection. The facility's policy and procedure on medication labeling and storage, dated February 2023, required medications to be stored under proper conditions and labeled with the resident's name and the open date for multi-dose vials.
Failure to Provide Correct Diet Texture for Resident with Dysphagia
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of a resident with dysphagia, who was ordered by the physician to be served a regular diet with mechanical soft texture. Despite the physician's order, the resident received regular texture food instead of the required mechanical soft texture from July 16, 2024, to October 3, 2024. This oversight placed the resident at risk for aspiration and choking. The resident, who was initially admitted on April 1, 2015, and readmitted with diagnoses including hemiplegia, hemiparesis, muscle weakness, cognitive communication deficit, aphasia, and dysphagia, had a care plan indicating a risk for aspiration and choking during meals. The care plan included interventions such as a mechanical soft diet with thin liquids and assistance during meals. However, during a dining observation on October 1, 2024, the resident was seen eating alone with no assistance and using a spoon to cut a large piece of chicken, indicating a failure to adhere to the prescribed diet texture. Interviews with facility staff revealed that the Dietary Service Supervisor was unaware of the mechanical soft texture order due to an error in transferring the diet order into the system, resulting in the resident receiving a regular texture diet. The Director of Nurses confirmed that the resident's diet order had been mechanical soft texture since July 16, 2023, and acknowledged the risk of aspiration or choking due to the incorrect diet texture being provided.
Failure to Timely Screen and Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to screen and offer the pneumococcal vaccine to a resident upon their initial admission, as required by the facility's policy. The resident, who was admitted with diagnoses including depression and low back pain, had moderately impaired cognitive skills and required varying levels of assistance with daily activities. The facility's policy mandates that assessments of pneumococcal vaccination status be conducted within five working days of admission. However, the Infection Preventionist (IP) did not screen the resident for the vaccine until 22 days after admission due to being occupied with other tasks. During interviews, both the IP and the Director of Nursing acknowledged the oversight. The IP admitted to not screening the resident in a timely manner, which delayed informing the resident about the vaccine and its protective benefits against pneumonia. The Director of Nursing confirmed that staff should screen residents for the pneumococcal vaccine upon admission to ensure they are informed and offered the vaccine to protect against pneumococcal infection.
Failure to Maintain Sanitary Bed Siderails
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for Resident 160, who was observed with stained and soiled upper bed siderails. Resident 160, admitted to the facility with diagnoses including depression and low back pain, had moderately impaired cognitive skills and required varying levels of assistance with daily activities. During an observation, Resident 160 reported that the siderails had been dirty since admission and that the maintenance supervisor was informed, but no cleaning was done. The resident expressed discomfort using the siderails due to their unclean state. Certified Nursing Assistant (CNA) 5 confirmed the siderails were dirty and stated that housekeeping was responsible for cleaning them. Housekeeping staff acknowledged that bed siderails are high-touch areas requiring daily cleaning to prevent infection spread but admitted to not cleaning Resident 160's siderails. The Director of Nursing also stated that staff should clean the siderails daily to maintain a sanitary environment. The facility's policy indicated that residents should be provided with a safe, clean, and comfortable environment.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its written abuse policy and procedure for two residents involved in a resident-to-resident altercation. Resident 106, who has schizophrenia and anxiety disorder, was allegedly physically abused by Resident 29, who also has schizophrenia and dementia. The incident occurred when Resident 29 poured a cup of water on Resident 106 while he was sleeping, leading to a confrontation in front of the nursing station. Despite the altercation, there was no documentation or investigation conducted by the facility. Interviews with staff revealed that the incident was not reported to the Director of Nursing (DON) or the Administrator (ADM) until informed by the surveyor. Licensed Vocational Nurse (LVN) 4 and Certified Nursing Assistant (CNA) 3 were aware of the altercation but did not report it, assuming the DON was already informed. The DON and ADM confirmed they were unaware of the incident and acknowledged that a thorough investigation should have been conducted to prevent recurrence and protect the residents. The facility's policy on abuse reporting and investigation requires immediate initiation of an investigation upon receiving a report of abuse. However, this procedure was not followed, as evidenced by the lack of documentation and investigation into the altercation between the two residents. The incident was only reported to the Department on a later date, indicating a failure to adhere to the facility's established protocols for handling such incidents.
Failure to Timely Report Resident Altercation
Penalty
Summary
The facility failed to report an allegation of physical abuse within the required two-hour timeframe, as per their policy. The incident involved two residents, Resident 106 and Resident 29, where Resident 106 alleged that Resident 29 poured water on him while he was asleep. This altercation was witnessed by LVN 4, who did not report it to the Abuse Coordinator or any other designated authority within the stipulated time. Additionally, CNA 3, who was aware of the incident, also failed to report it immediately. The Social Services Director eventually reported the incident to the enforcement agencies eight days later. Resident 106, who has diagnoses of schizophrenia and anxiety disorder, was admitted to the facility on 9/13/2024. The Minimum Data Set (MDS) indicated that Resident 106 had moderately impaired cognitive skills and required assistance with daily activities. Resident 29, who has schizophrenia and dementia, was readmitted to the facility and also had moderately impaired cognitive skills. The altercation occurred shortly after Resident 29 was transferred to Resident 106's room, and there was no documentation of the incident in the progress notes of either resident. Interviews with staff revealed a lack of communication and reporting. LVN 4 assumed the Director of Nursing (DON) was aware of the incident because she was present in the facility at the time, but the DON stated she was not informed until the surveyor brought it to her attention. The Administrator also confirmed that neither he nor the DON knew about the altercation until the surveyor's notification. The facility's policy requires all allegations of abuse to be reported immediately to the appropriate agencies, which was not adhered to in this case.
Failure to Supervise Resident on Temporary Leave
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who went out on pass (OOP) and did not return at the expected time. The resident, who had diagnoses including major depressive disorder, schizoaffective disorder, bipolar type, and hypertension, was allowed to leave the facility with an estimated return time of 12:00 PM. However, the resident did not return until more than 24 hours later, during which time the facility did not escalate the situation by notifying the Medical Doctor (MD), Director of Nurses (DON), or Social Worker (SW) for guidance. The resident's absence was not reported to law enforcement or other appropriate agencies until more than 24 hours after the expected return time. This delay in notification was a result of the staff's failure to escalate the issue to upper management when the resident did not return. Interviews with the DON, SW, and nursing staff revealed that the resident's whereabouts should have been addressed immediately, and the failure to do so was acknowledged as a safety issue. The resident returned to the facility feeling tired, with untidy clothes and dirty hands and feet, and had missed two days of scheduled medications, including those for depression, hypertension, and schizophrenia. The facility's policy and procedure for signing residents out was not adequately followed, as the OOP order did not specify the duration the resident was allowed to be out, and the staff did not ensure the resident's safety by knowing their whereabouts or providing necessary medications during the absence.
Inadequate Supervision of Resident with Wandering Behavior
Penalty
Summary
The facility failed to provide adequate supervision for a resident with severe cognitive impairment and a history of wandering behavior. The resident, diagnosed with dementia and Alzheimer's disease, was admitted with a care plan that required monitoring every hour and visual checks every two hours. However, documentation showed that the resident was only monitored every shift, and there was no evidence of 1:1 supervision as needed, despite the resident's known wandering behavior. An altercation occurred between the resident and another resident when the wandering resident entered the other's room, resulting in a physical assault. Although the resident did not sustain injuries from the altercation, the incident highlighted the lack of adequate supervision. Interviews with facility staff, including the DON and an LVN, revealed inconsistencies in monitoring practices, with staff acknowledging that the resident's wandering was a known issue but not consistently addressed according to the care plan and physician orders. Further observations showed the resident was found on the floor in their room, with no immediate response from the attending CNA, who was assisting another resident in the same room. The CNA was unaware of the resident's fall, indicating a lapse in supervision. The facility's policies on wandering and elopement were not effectively implemented, as evidenced by the lack of a person-centered approach to prevent such incidents, despite the resident being identified as a fall risk.
Failure to Address Dementia-Related Behaviors
Penalty
Summary
The facility failed to comprehensively assess and address the behavioral symptoms of a resident diagnosed with dementia, leading to a deficiency in care. The resident, who was admitted with diagnoses including dementia with behavioral disturbances, schizoaffective disorder, anxiety disorder, and Alzheimer's disease, displayed wandering behavior and had a history of entering other residents' rooms. Despite these behaviors, the facility did not develop a specific dementia care plan or conduct an interdisciplinary team (IDT) meeting to address the resident's needs. The resident's care plan indicated a need for monitoring due to the risk of injury from wandering, with interventions including visual checks every two hours and 1:1 supervision as needed. However, documentation showed that the resident was only monitored hourly for a short period and did not receive the required 1:1 supervision. An altercation occurred when the resident entered another resident's room, resulting in the resident being physically assaulted. Despite this incident, the facility did not adjust the care plan to provide adequate supervision or address the resident's wandering behavior effectively. Observations revealed that the resident was found on the floor in their room without any alarm sounding, indicating a lack of appropriate safety measures. Staff interviews confirmed that the resident's wandering was considered normal, yet no specific interventions were in place to prevent incidents. The Director of Nursing acknowledged that a dementia care plan was not created or implemented, and there was no record of an IDT meeting to address the resident's dementia-related behaviors.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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